Interrupting the cycle: A personal journey through pain reprocessing therapy

“It’s almost as if my body doesn’t know how to not be in pain.”

When I said this to a friend in the fall of 2024, I’d had a persistent, dull ache in my lower back for months. It was relentless and disruptive, derailing my daily routines and bringing my training as a triathlete to a screeching halt. I thought I had aggravated an old childhood injury, and the pain felt deeply familiar — both physically and psychologically.

Since the age of 11, physical pain had been a consistent, unpleasant hum in the background of my life. A long recovery from back surgery in middle school gave way to chronic migraine as a teenager, which lasted for decades. When my back started hurting again in my mid-30s, X-rays and MRIs revealed no acute injury, only mild degeneration around the hardware that is typical decades after spinal fusion. My orthopaedist sent me to physical therapy, and given my history as an athlete, we both assumed I’d be feeling strong again in a matter of months.

Nearly a year later, despite following my doctor’s every order, I still had a low-grade ache nearly every day, with frequent, unpredictable spikes in intensity. Even the most ordinary movements could trigger debilitating flare-ups — once, squatting down to pick up my cat left me in so much pain that I missed two days of work, canceled a long-planned trip and took an extended break from all physical activity.

What was I doing wrong? After months of PT, how was I still so fragile? Why was I, yet again, stuck in a seemingly endless cycle of pain?

Sensing my frustration, a physical therapist eventually introduced me to a concept that might explain and validate these patterns: neuroplastic pain, a form of chronic pain driven by an oversensitive nervous system rather than ongoing structural damage. The treatment? Psychotherapy.

At first, the idea of a psychological solution to a physical problem felt difficult to reconcile. But clearly, my attempts at physical treatments — PT, dry needling, cortisone shots, myofascial massage, muscle relaxers — weren’t working for me. Mind-body approaches like pain reprocessing therapy, which are backed by decades of neuroscience, are helping providers and patients rethink the relationship between the brain and chronic pain. And at the VCU School of Medicine, researchers and clinicians are working to better understand neuroplastic pain, help people recover and expand access to treatments that often remain outside the medical mainstream.

The pain isn’t in your head — it’s in your brain

Neuroplasticity is the brain’s ongoing ability to rewire its neural pathways in response to new experiences — it’s what allows us to learn to ride a bike or play a musical instrument. Normally, this adaptive process helps the nervous system protect the body after a physical injury by sending and regulating pain signals, with symptoms gradually fading as healing occurs. But in some cases, that response becomes maladaptive. In a process known as central sensitization, the nervous system can grow increasingly reactive to potential threats, lowering the threshold for triggering pain and amplifying pain signals even in the absence of ongoing tissue damage. When the nervous system becomes overly sensitive to danger, pain can become neuroplastic.

When Taylor Crouch, Ph.D., an assistant professor and researcher in the Department of Psychiatry, explains neuroplastic pain to a patient for the first time, she often compares it to a malfunctioning smoke detector.

“With acute pain, the alarm is going off because there’s smoke in the kitchen, and it’s telling us there is a fire,” she said. “With neuroplastic pain, the problem is that the alarm’s going off — that’s not imagined; it’s very real — but not because of a fire. It’s going off because the sensor has become faulty over time and is too sensitive.”

In her practice as a pain therapist, Crouch said this metaphor can help patients understand that their symptoms aren't made up, or "in their head," and that the brain produces pain in response to a real or perceived threat. She then tells patients the reassuring news: If the brain can learn and get stuck in these patterns, it can also unlearn them through methods like pain reprocessing therapy (PRT).

PRT combines mindfulness, exposure and other somatic and emotion-based techniques to help patients identify patterns, teach their brain to interpret symptoms as non-dangerous, calm their nervous system and ultimately feel relief from the physical pain. A randomized clinical trial published in JAMA Psychiatry in 2021 found that PRT led to large reductions in the severity of chronic back pain, and 66% of patients who participated in PRT were pain-free or nearly pain-free one year after treatment.

When working with a new patient, Crouch starts by asking questions: What triggers your symptoms? Does the pain change from day to day? Do your symptoms increase with stress? What treatments and coping mechanisms have and have not worked so far? With this information, she can help the patient identify red flags of neuroplastic pain and understand whether their symptoms may be caused by an overly sensitive nervous system.

“The more someone is personally involved in building this evidence list, the more they understand it and buy into it, rather than someone just telling them what’s happening in their body,” Crouch said.

This rang true as I put together my own list with a Richmond-area pain therapist. The deeper we dug into these factors — Do some activities hurt one day and feel fine the next? Yes. Do you feel anxious about worsening symptoms? Always. Do you have a propensity for perfectionism? How’d you know? — the more validated I felt. This therapist introduced me to the concept of pain as a biopsychosocial experience, meaning it's shaped not just by what's happening in the body, but also by psychological and social factors such as family history, past trauma and stress. She was not surprised to learn that my mom and I have both had chronic migraine for decades, and she gently explained that a constant stream of self-criticism can keep my nervous system on high alert and primed for danger.

Understanding the neuroplastic patterns in my long history of pain was empowering. For the first time in well over a year, I felt something resembling hope, and in February of 2026 I began learning and practicing the components of PRT in earnest.

‘It’s big work, and it’s not easy’

A core element of PRT is a mindfulness technique called somatic tracking. It involves identifying objective characteristics of the pain — Is it hot, cold, dull, sharp, pinching, tingly? Is it moving around, pulsing, growing, shrinking? — rather than labeling it as bad or dangerous. By acknowledging that the sensation is neutral, temporary and not a threat, the practice can create new neural pathways that reduce the brain’s sense of danger around the symptoms and interrupt the cycle of fear and pain.  

Another piece of this therapy is digging into personality traits and habits that can, inadvertently, fuel the pain-fear cycle. PRT teaches that while qualities like people-pleasing, perfectionism and rumination may have originally developed as protection during “both big T and little t traumas,” they can become a person’s default mode over time. To fully embrace and benefit from PRT, there must be a willingness to examine hard truths and sit with uncomfortable feelings.

For me, the most enlightening discovery during this therapy was the hypervigilance that I developed at a young age.

When I was experiencing more than a dozen migraine days a month, preventing and managing pain was part of my everyday life. I meticulously tracked potential triggers and rarely left home without a small arsenal of supplies like sunglasses, snacks, water and medications. When my back pain returned, I became a gold-star patient. I diligently completed my PT exercises every evening. I adhered to my doctor’s instructions to avoid bending, twisting and lifting anything heavier than a gallon of milk, which meant relying on my husband for everything from carrying groceries to scooping the litter box. I used ice packs, heating pads, lidocaine patches, a lumbar support pillow and muscle relaxers to get through the day. I stretched and went for walks between meetings to limit long periods of sitting.

With both conditions, I was constantly on alert, scanning my surroundings and my body for pain signals and bracing myself for a flare-up. These practices gave me a sense of control. The diligence felt productive, responsible and even virtuous — friends and family admired my discipline and commitment to my physical health. But as I’ve learned through PRT, these tendencies signaled to my nervous system that danger was always present, which can perpetuate the very symptoms I was trying to prevent.

To help me better understand how my hypervigilance and other personality traits may affect my pain, my therapist gave me a list of questions to explore in writing. I’ve spent hours scribbling responses to prompts like “What does this part of you desire most deeply?” and “What does this part of you fear would happen if it stopped doing its job?”

I’m no stranger to therapy — or writing for hours on end, for that matter — but this kind of emotional excavation pushed me into new territory. It forced me to face how this habit of scanning my surroundings for danger shows up in other corners of my life, such as social anxiety and a frequent, nagging belief that someone must be mad at me. Crouch said many patients are surprised to discover that addressing neuroplastic pain can require this kind of intensive self-examination.

“Neuroplastic pain can impact, and be impacted by, how people relate to themselves and the world, and sometimes we have to really look at those things and try to make major changes,” Crouch said. “It’s big work, and it’s not easy.”

Bridging the gaps 

Unlike many core areas of medical training, the Association of American Medical Colleges does not mandate a minimum amount of instruction time on pain in M.D. curricula. A 2019 study revealed that U.S. medical students receive an average of 11 hours of pain education — with pain and pain-related diseases being the leading cause of disability worldwide, this is widely cited as a major gap in preparing physicians for modern practice.

According to Crouch, one piece of the solution is for pain experts to share knowledge and materials with providers across specialties. Physicians need resources and support, she said, because "these are complex ideas to try and explain in a 10-minute visit with a patient."

Crouch said she feels lucky to work closely with doctors across VCU Health who see the value in this model of care. Among those advocates is Brandon Wills, D.O., a professor in the Departments of Emergency Medicine and Psychiatry.

As medical director of VCU’s outpatient addiction medicine clinic, MOTIVATE, Wills regularly sees patients navigating both chronic pain and substance use disorders. After connecting with Crouch and completing a PRT training course, Wills developed a five-session treatment plan that he hopes will help patients incorporate pain reprocessing principles into their care.

He noted that while MOTIVATE is not a pain clinic, he sees a lot of similarities between his and Crouch’s patients.

“One of the key concepts of substance use disorder is that it’s a learned disorder, like the centralized pain loop is learned,” Wills said. “It’s time to start working with these patients differently, rather than being only medication-focused, and helping them have a better quality of life.”

That improved quality of life is what motivates Crouch as a researcher. She’s expanding her chronic pain work and studying neuroplastic patterns associated with disorders like postural orthostatic tachycardia syndrome (POTS) and sickle cell disease, and findings indicate that a sensitized nervous system may play a role even in conditions with clear structural origins. The goal, she said, is to better understand how neuroplastic mechanisms contribute to pain and, ultimately, make potentially life-changing treatments widely available to providers and patients across the medical field.

“We have a systemic misunderstanding of pain in our society, and I think addressing those gaps is really important,” Crouch said. “We can’t solve this on the individual patient level alone.”

More than an injury 

Mary Caldwell, D.O., a sports medicine physician and associate professor in the Department of Physical Medicine and Rehabilitation, has incorporated components of PRT into her practice for years, and she often refers patients to pain therapists like Crouch. She introduces the concepts early on, alongside physical and manual therapies, and said these techniques can help prevent acute pain from becoming chronic.

Whether treating an elite soccer player with a career-threatening fracture or a hobbyist runner with chronic shin splints, Caldwell leads with a core philosophy:

“The injury doesn’t define you,” she said. “The second you let an injury define you is kind of the second centralized pain can start to play a role.”

Caldwell was not one of my providers at the time, and I didn’t realize until meeting her how profoundly I needed to hear that. As an avid (though supremely average) runner and cyclist, I lost my stress relief, a social outlet and part of my identity when my back pain returned two years ago. The medical professionals I saw were sympathetic, but the overwhelming message was that, yes, I would probably deal with this pain forever. My ortho said that running and cycling were unlikely to cause further structural damage, so it was up to me to decide whether I was willing to tolerate the increased symptoms that came along with my favorite activities.

Now, about six months into PRT, I’m starting to feel like myself again.

Before starting this treatment, every zap of back pain during a workout sent me spiraling down a “What if I did permanent damage and this is my life forever” rabbit hole. But PRT teaches that immediately stopping an activity at the first sign of familiar pain would signal to my nervous system that the activity is dangerous, and it could continue producing that ache in response. So as a runner, the goal is to create neural pathways that teach my brain to associate running with safety, not with pain.

Now, if my symptoms show up during a run, I repeat a mantra in my head that running is safe, and not causing me physical harm. I then try to redirect my attention, usually toward the trees or my stride, to prevent my brain from switching into its hypervigilant mode of scanning for danger. More often than not, this sequence works for me, and the pain dissipates within a few minutes.

This therapy isn’t a replacement for seeing a physician for new pain or an acute injury. If I fly over the handlebars on a bike ride and my vision goes blurry, I’ll obviously go to the emergency department. It also isn’t in a vacuum — I still do my PT exercises for strength and mobility, especially before a run, and I’ll continue seeing my doctor every year. But since learning these techniques, I’ve been able to gradually increase my running intervals and I’m back to cycling and weightlifting. Extended periods of sitting no longer trigger my symptoms, even on the 14-hour flight to Japan I took in June.

My therapist cautioned that I'm not immune to flare-ups, and I had one in August that shook my confidence — I had to wallow in it for a few days before resuming the PRT practices and getting back to my new baseline of being largely pain-free. It's not a perfect process, and it's not easy. But these tools have consistently helped me manage both my physical symptoms and my fear around them.

After more than 25 years, it feels like my body is finally beginning to learn something other than pain.