(Photo courtesy of Jeana Iwalani Naluai of Ho’omana Spa Maui)
Most chronic pain explanations are often attributed to biomechanics, physiological factors or both. Not surprisingly, most treatments are often based on these reasons, such as surgery, medications, posture correction, and joint manipulation.
However, a group of researchers—led by Dr. Lene Vase from Aarhus University in Denmark—highlighted core principles of psychological interventions that can change how people manage their chronic pain.
According to their review published in Lancet in 2025, psychological interventions, such as cognitive behavioral therapy (CBT), can gradually alter some people’s behavior and beliefs about their pain. These changes primarily occur in the default mode network (DMN) in the brain, which are regions that are active when you’re at rest or self-reflection, such as daydreaming or thinking about the past or the future.
DMN regions include the ventromedial prefrontal cortex (VMPC), ventrolateral cortices, orbitofrontal cortices, lateral temporal cortex, posterior cingulate cortex (PCC), inferior parietal lobule (including angular gyrus), and the hippocampus.
- Ventromedial prefrontal cortex (vmPFC): Self-reflection, decision-making, and emotion regulation.
- Posterior cingulate cortex (PCC) and precuneus: Memory, consciousness, and internal thought.
- Inferior parietal lobule (including angular gyrus): Integrating sensory information and understanding others’ perspectives.
- Lateral temporal cortex: Helps with language and autobiographical memory.
- Hippocampus and parahippocampal gyrus: Memory formation and mental time travel (thinking about past and future).
(See image for default mode network)
In people with chronic pain, the DMN’s normal activity is disrupted, and it connects more with areas involved in sensing pain, which can make pain feel stronger and interfere with memory and thinking skills.
Vase and her colleagues Dr. Tor D. Wager and Dr. Christopher Eccleston wrote that changes in the brain that promote pain can be grouped into five general types, even though they are closely connected and not easily separated in practice. These include:
- Increased sensitivity in pathways that carry nociceptive signals toward the central nervous system.
- A shift in brain systems that normally dampen pain, making them more likely to increase pain instead.
- Changes in brain areas that deal with learning about threats and motivation, leading to stronger reactions to pain-related cues and a focus on avoiding future threats.
- Changes in systems related to reward and exploration, which encourage social and behavioral withdrawal.
- Changes in brain areas that connect higher thinking, emotions, and motivation—especially those involved in adjusting behavior based on personal abilities and the surrounding environment.
While they acknowledge that changes in their brain pathways may enhance or decrease chronic pain, which types of change may happen depend on the type of injury or insult, type of pain-related behavior, and time of assessment during the chronification and recovery processes.
“It is not clear to date which human pathways and networks are directly involved in shaping the pain experience or are activated indirectly due to the widespread effects of chronic pain,” Vase et al. wrote.
The researchers also wrote that brain imaging studies show that psychotherapy can help with pain by affecting specific brain areas, such as the cingulate cortex and insula. These areas are known to process pain in both humans and animals. Other brain areas, such as DMN, don’t directly sense pain but still seem to change in ways that support chronic pain.
“For example, chronic pain is associated with grey matter decreases in regions associated with DMN and alterations in its functional connectivity,” they wrote, adding that those who have chronic pain for a long time have such connections changed.
Some changes in the DMN and related brain systems may happen before chronic pain develops, Vase et al. wrote, suggesting they might make a person more likely to develop chronic pain after an injury. For instance, if the DMN is more strongly connected to areas like the nucleus accumbens (which is involved in motivation) or sensorimotor regions, the person might be at higher risk for chronic pain in the future.
The ventromedial prefrontal cortex (vmPFC) plays a significant role in controlling nociception, Vase et al. continued. This region connects to brain areas that reduce pain, such as the periaqueductal gray and the nucleus accumbens.
Research in both animals and humans shows that the vmPFC can change pain behavior and may help regulate pain via descending modulation. Besides pain, the vmPFC also helps with decision-making and body regulation, which means it could be an important link between mental health treatments and changes in how people feel pain.
Evidence in neurobiology
Even though there’s growing evidence that psychological therapies can help with chronic pain, not many studies have looked at how these treatments affect the brain, Vase et al. wrote. The authors did a review of clinical studies that used brain scans before and after therapy, along with reports of how patients were feeling. They found nine studies that met these criteria.
From these studies, they noticed four main brain-related effects of psychological treatment, each involving different brain systems and are supported by at least two studies:
- Changes in the DMN and connected subcortical regions related to emotion and pain control, like the periaqueductal grey.
- Changes in the lateral prefrontal cortex and orbitofrontal cortex, which help people understand their situation and manage their behavior.
- Lower activity in the anterior midcingulate and anterior insula, areas that play a role in sensing pain, body awareness, and decision-making.
- New patterns of connection between major brain systems, including links between the DMN, the anterior insula, and areas that process touch and movement like the primary somatosensory cortex.
While these studies offer a glimpse to how psychological interventions may affect neurobiology, Vase et al. wrote it is “unclear” what the observed changes mean. For example, they might show:
- Actual changes in how the brain processes pain
- Changes in things that come with pain (like fear or negative thinking)
- Brain changes happen simply because the pain improved on its own
Because of these uncertainties, scientists and clinicians need to be careful when interpreting these results.
“We can see converging evidence from animal and human studies, but it can be difficult to pinpoint when networks are directly involved in shaping the pain experience or are activated indirectly due to the widespread effects of chronic pain,” Vase told Massage & Fitness.
Role of psychological interventions
There are different ways that clinicians can deliver psychological interventions, from in-person therapy to smartphone apps. Vase et al. pointed to a 2023 Cochrane Review that reviewed the benefits and harms of remotely-delivered psychological therapies. The review included 32 randomized-controlled trials with more than 4,900 adults. The treatment is compared to an active control, a waiting list, or usual treatment for chronic pain management.
The Cochrane Review authors reported that remote cognitive behavioral therapy (CBT) provides “small benefits for pain intensity (moderate certainty) and functional disability (moderate to low certainty) in adults experiencing chronic pain.” However, they wrote remote acceptance and commitment therapy (ACT) has “limited and of very low certainty.”
“It is unclear whether other psychological therapies can also be successfully translated to remote delivery, given the evidence available,” they concluded.
[See graph of the evidence strength vs. treatment availability]
“A common feature for most pain interventions is the focus on flexibly unlearning and relearning the value of a chronic pain signal, what it does
and does not mean, and how it can be used differently to improve engagement with meaningful and valued life activities,” Vase et al. wrote. “There are many techniques and technologies for delivering these core features…and they emerge from different traditions of psychotherapy, foundational experimental studies, and clinical experience.”
Vase told Massage & Fitness that such an inverse relationship between the quality of evidence and type of intervention exists because it takes a long time and costs a lot of money to provide solid evidence that a treatment works.
“CBT has been around for a long time and numerous studies have been conducted here,” she said. “Many digital therapies are new, and they have yet to provide evidence.”
Creating opportunities for pain self-management
Vase et al. provided several actions that clinicians—even non-psychologists—may do to create opportunities for patients to self-manage their chronic pain within their scope of practice. These are based on principles of CBT.
- Acknowledge the patients’ pain is real and be supportive in understanding and aiding in self-management.
- Offer a brain-based explanation to explain pain without observable pathology.
- Assess the patients’ core beliefs about their pain and how rigid or flexible are their beliefs.
- Introduce alternative ways to think about pain, such as focusing on function instead of pain.
- Provide ideas of supported self-management, such as focusing on activities that are valuable to patients.
- Provide resources and options to reinforce key messages in beliefs about pain. This may involve the patients’ significant other or close allies.
- Create a time scale that helps with goal setting.
“All community or health-care encounters offer an opportunity to alter the patient’s trajectory to self-management,” the authors wrote. “Arguably, these health-care encounters could be improved by specific training in long-term conditions and pain, but we suggested that all community and health-care providers can benefit patients by considering a broad biopsychosocial framework to guide those clinical encounters.”
Putting it in practice
Massage therapists can apply psychological concepts related to chronic pain by focusing on providing a supportive, calming environment (e.g. treatment room ambiance) and providing basic, science-informed education—without stepping outside their scope of practice.
For example, they can explain in simple terms how pain is not just caused by mechanical factors but also influenced by the brain, stress, and emotions. During the sessions, they can ask clients to notice areas of tension or how they feel when they apply pressure or touch in such areas.
Registered massage therapist Rachel Ah Kit of Bodyworks Massage Therapy in Christchurch, New Zealand, said in an interview with Massage & Fitness that how massage therapists apply psychological principles to their practice also depends on their scope of practice based on their location.
“In New Zealand, since [massage therapy is] not regulated, the scope of practice is pretty broad. We can provide any treatment or therapy if we are ‘trained and authorised to do so,’” Ah Kit said. “I’m aware of some locations where so-called ‘talk-therapy’ is not permitted, but I believe that if we are providing person-centred care, then we are simply engaging in communication with the client, not providing specific talk-therapy or any other psychological intervention.”
Ah Kit said that understanding how psychological interventions provide an opportunity for bringing “psychologically-informed approach” to massage therapy practice. This means asking questions to clients about their thoughts, beliefs, feelings, and behaviors that influence their pain experiences, she said.
“Massage therapists can then help clients reframe or ‘unstick’ from those thoughts and beliefs by assisting clients to experience a new way of noticing their own bodily sensations or encouraging them to move in new ways,” Ah Kit said.
She gave an example of a client who has chronic low back pain with no clear diagnosis after seeing his primary-care physician and several physiotherapists.
“I first ask him, ‘So what do you think is going on?’ This helps me understand his own beliefs,” Ah Kit said. “I’d ask him, ‘What important activities is this pain restricting you or preventing you from doing?’ This gives me an idea of what’s of value to him.”
She found out that her client enjoys golf and that the pain may affect his ability to play. “I’d validate his pain experience with something like, “So, it sounds like you really enjoy golf and spending time with your golfing buddies. That’s great. But you’re concerned that playing will flare up this low back pain or make it worse, so you’ve stopped playing. That must be hard for you.’ I might also enquire about how much pain he’d be willing to endure to be back playing golf.”
During the session, the hands-on work is used not to fix something “broken,” but to help the client feel safer and more at ease in his body. Ah Kit said that she is always careful of her language and avoids phrases like, “Oooh, that’s tight” or pointing out body asymmetries or areas of “dysfunction.” Language is carefully chosen to avoid reinforcing fear or dysfunction.
“These can increase any perception of his body being a ‘bit broken’,” she said. “I’m more interested in using touch to help him feel better about his own body, not worse. If he can relax, his body will also respond differently to movement. After that, I’d get him back off the table to repeat the [golf] swinging movement, asking him to notice how different it feels, what he notices now.”
She said the session includes elements inspired by CBT and ACT, not as formal therapy but as a collaborative approach to help the client build confidence and reclaim meaningful activities.
“We’re creating a safe space for clients to develop their own insights while we provide the hands-on therapy (and possibly movement education) that falls within our professional boundaries,” Ah Kit said. “We have an opportunity to help them increase their self-efficacy. A psychologically-informed approach simply helps us understand the appropriate questions to ask and what observations to share that might support their self-management journey.”
Regarding future research, Vase said that It would be helpful to know more about the specific mechanisms of psychotherapy and how they relate to brain based mechanisms.
“Also, It would be helpful to get a better understanding of how healthcare professionals can communicate with patients to facilitate pain relief,” she said. “Manual therapists [should] be able to start a conversation on core beliefs on cause and consequences of pain and to introduce alternative ways of thinking about pain. Sometimes a more flexible approach to the understanding of pain—what causes it and how should I react to it—may help patients stay engaged in valued life activities and improve quality of life and possibly reduce pain levels.”
Nick Ng is the editor of Massage & Fitness Magazine and the managing editor for My Neighborhood News Network.
An alumni from San Diego State University with a bachelor’s in graphic communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. In 2021, he earned an associate degree in journalism at Palomar College.
When he gets a chance, he enjoys weightlifting at the gym, salsa dancing, and exploring new areas in the Puget Sound area in Washington state.
