Physical Therapy for Psychogenic Pain: An Integrative Approach

Can physical therapy help when tests don't show anything?

Physical therapy can help you resume activities and manage persistent pain, even if tests do not reveal a specific injury that fully explains it. The physical therapist tailors education, movements, and exercises to your assessment. Recommendations for movement difficulties related to nervous system function and a review on pain education support some of these approaches in the studied populations.^{1, 2} Your pain is very real. Normal test results are not sufficient to identify its mechanism. Nociplastic pain, linked to a change in how the nervous system processes signals, can sometimes contribute to symptoms. A 2021 review reports that this mechanism affects an estimated 5 to 15% of the general population and can coexist with other mechanisms.³

Results depend on the condition being treated. The Physio4FMD trial, published in 2024, enrolled 355 adults with a functional motor disorder—that is, movement difficulties caused by the functioning of the nervous system rather than by an identifiable lesion. Diagnosis is based on a medical evaluation and characteristic signs. The program tailored to this disorder was compared to standard neurological physical therapy, which focuses on difficulties related to the nervous system. At 12 months, the primary measure of physical function showed no clear difference between the groups. However, participants in the tailored program reported improvements in motor symptoms more often; their mental health scores were also better. Both approaches were well-received, and no serious adverse events were attributed to the care. These results pertain to functional motor disorders, not directly to a population defined by so-called psychogenic pain.⁴

What science teaches us:

• Your pain deserves to be taken seriously, even when there is no underlying medical condition to explain it yet.⁵
• Physical therapy, psychotherapy—which provides psychological support—and medication can play complementary roles, depending on the diagnosis and your needs. A combination of these approaches is not necessary for everyone.^{6, 7}
• Trust and collaboration with the therapist are associated with better outcomes in a study on chronic back pain. This link alone does not prove that the relationship with the therapist led to the improvement.⁸
• Graded motor imagery uses left-right recognition, imagined movements, and a mirror. Small studies suggest it may be beneficial for certain types of persistent limb pain.⁹

This guide explains how physical therapy can help you regain confidence in your movements and better manage your pain. Our page on psychogenic or somatic pain also explains why these terms require distinction.

What does the term “psychogenic pain” mean?

The term “psychogenic pain” has historically referred to pain attributed to psychological factors; it is not another name for nociplastic pain. Pain may persist for more than three months, become chronic, and not be fully explained by a visible injury. This situation alone is not sufficient to establish a psychological origin. Biological, psychological, and social factors influence the experience of pain, with their contributions varying from person to person.^{10, 11, 12} Pain is neither imagined nor feigned.

The terms “somatoform,” “functional,” and “psychogenic” have been used to describe different conditions. Somatic symptom disorder involves distressing symptoms accompanied by excessive thoughts, emotions, or behaviors related to those symptoms. A physical illness may or may not be present. The absence of an identified cause is not sufficient to make this diagnosis.¹³Nociplastive pain, on the other hand, describes an alteration in nociception—the nervous system’s processing of potentially harmful signals. It does not automatically imply a psychological disorder.¹⁴

Stress, emotions, sleep, and social context can contribute to the development or persistence of chronic pain. They can also influence how you cope and respond to treatment. Their role should be evaluated alongside other factors, without concluding that any one emotion alone explains your pain.¹⁵

Situations to Discuss During the Evaluation

An assessment may examine the following situations, without considering them as evidence of a psychological cause:

• Your pain persists even though no tissue damage fully explains it.
• X-rays or magnetic resonance imaging—a test that produces detailed images of the body—do not explain the severity of the symptoms.
• Your pain varies in intensity or location.
• Stress or emotions seem to affect your symptoms.

Real pain, real mechanisms

Pain is an experience that involves the brain, the body, and one’s life context. It is not a direct measure of tissue damage.^{16, 10} The nervous system can become more sensitive. Central sensitization refers to an increased response of certain neurons—nerve cells—in the brain and spinal cord to their usual signals. This phenomenon can contribute to various types of pain. It cannot be inferred simply from a normal X-ray, and your pain remains real even if its mechanism is unclear.¹⁷

Nociplastive mechanisms may involve signal processing in the brain and spinal cord, as well as factors in the nerves and tissues of the rest of the body. Interactions with the immune system, which plays a role in the body’s defenses, are also being studied. These mechanisms are not yet fully understood.¹⁸

Understanding the possible mechanisms can help you discuss your care. Chronic pain may involve several mechanisms, which guide treatment decisions.

How does physical therapy help people suffering from psychogenic pain?

Physical therapy helps people with so-called psychogenic pain understand their symptoms, regain movement, and continue their activities. The treatment plan takes into account the body, thoughts, emotions, and life context: this is a biopsychosocial approach. Similar principles guide the care of functional motor disorders, but treatments must remain tailored to the diagnosis.^{1, 7}

Physical therapy takes into account the tissues and other factors that influence pain. In cases of persistent pain, the treatment plan may place greater emphasis on the following goals:

Understanding Pain Better

The physical therapist explains why persistent pain does not necessarily mean that an injury is getting worse. This information can help reduce fear and restore confidence in the movements we’ve chosen together.²

Adjusting Movement Habits

A person with chronic pain may avoid certain movements to protect themselves. While this protection can be helpful, it can also limit activities if it continues unnecessarily. The physical therapist helps patients try adapted movements and rediscover new options. Our approach to movement rehabilitation—which involves practicing and adapting movements—is an integral part of this process.¹⁹

Reducing Fear of Movement

Kinesiophobia is a significant fear of moving or getting injured. A review of 63 studies found strong evidence showing an association between greater fear and increased pain or difficulty with activities.²⁰ The strength of this finding does not mean that fear alone explains the pain. Most studies described a link at a specific point in time; they could not establish a single cause. The physical therapist may recommend gradual exposure, which involves resuming feared activities in stages.

A review of 31 studies on pain in muscles, joints, and other musculoskeletal structures compared various treatments, either directly or through meta-analyses across studies. Programs that combined multiple approaches scored highest in terms of reducing fear of movement. This finding supports their value, though it does not identify a single program that would be suitable for everyone.²¹

Developing self-management

A physical therapist helps you manage your symptoms on a daily basis. You’ll learn how to adjust your exercises, use relaxation techniques, and monitor your response to activities.

In Physio4FMD, the program for functional motor disorders consisted of nine sessions and a follow-up visit. The movement difficulties studied could take the form of weakness or involuntary movements. At 12 months, several secondary outcomes—including perceived improvement in motor symptoms and mental health—supported this program. However, the primary measure of physical function did not show a clear difference compared to standard neurological physical therapy.⁴ The choice of treatment for persistent pain also depends on the patient’s own assessment of the pain.

What is education in pain neuroscience?

Education in pain neuroscience explains how the nervous system, the body, and the context influence pain. It helps us understand why pain intensity is not a direct measure of the severity of an injury.¹⁶ It can be used in conjunction with other treatments. A clinical report describes, for example, its use in combination with motor imagery and progressive activities in a person with complex regional pain syndrome—a condition characterized by persistent pain in a limb accompanied by other changes, such as unusual sensitivity, color, or temperature.²²

The Fundamental Principles

Pain education covers several useful concepts:

Pain can serve as a warning signal. It can help protect the body, but its intensity is not a direct measure of the damage. The image of an overly sensitive detector can help illustrate certain types of persistent pain. This comparison does not mean that every movement is risk-free.

The nervous system may become more sensitive. After an injury, certain nerve responses may be amplified. This sensitivity alone is not enough to explain all pain or to identify its cause in an individual.

Pain can change over time. Education can reduce fear, while other forms of care support a return to normal activities. Pain may persist even as quality of life improves.^{2, 7}

How does the education system work?

The physical therapist uses visuals and explanations tailored to your questions. In particular, they may address the following points:

• An overly sensitive smoke detector illustrates how certain protective responses can be amplified.
• Thoughts and emotions can influence the experience of pain.
• Certain movements may still be possible despite the pain.

What benefits have been observed?

A 2019 review included 12 trials—involving 755 adults—on pain education for persistent muscle and joint pain. It found the following results:

• Education reduces fear of movement in the short term, with an effect deemed clinically relevant—that is, significant enough to have practical importance.
• People can better understand their pain when the instruction takes their history into account and allows them to ask questions.
• The average effects on pain and difficulties with daily activities remain modest and of limited clinical significance in this review.²

This approach is part ofthe care we provide to our patients.

How does graded motor imagery work?

Graded motor imagery involves performing three tasks in sequence: distinguishing between left and right, imagining movements, and then watching those movements in a mirror. This program has been studied, in particular, in people with complex regional pain syndrome or pain felt in an amputated limb, known as phantom limb pain.²³

In the 2006 trial involving 51 people, each phase lasted two weeks, for a total of six weeks.²³ The table describes this study protocol. Your physical therapist will tailor the program to your situation and your response.

What changes have been observed in the brain?

A study followed 21 people with complex regional pain syndrome of the upper limb—that is, the arm or hand. It observed changes in the activity of certain brain regions and a reduction in pain during movement after six weeks of motor imagery. These changes do not prove that an altered “brain map” causes the pain. The main comparison of changes in pain during movement between the treatment and wait-and-see groups remained inconclusive, and the pain-relief benefit was not observed at six months. This small study helps explore the mechanisms; it does not demonstrate efficacy for all types of persistent pain.²⁴

Search results

A 2013 review synthesized the results of several studies. For the comprehensive program, two studies involving a total of 63 participants showed that motor imagery was more effective than standard physical therapy. The standardized difference was 1.06, a measure that allows for the comparison of different scales and suggests a large effect. This number does not represent a 1.06-point decrease on a pain scale. The small sample sizes and the overall low quality of the studies limit the certainty of the findings.⁹ The indications therefore require some distinctions:

• Complex regional pain syndrome is one of the conditions being studied.
• Phantom limb pain has also been studied; however, this does not indicate an effect for all pain in an arm or leg.
• Functional motor disorders require a separate evaluation. Findings related to pain in a limb alone are not sufficient to systematically recommend motor imaging.

What is movement exposure therapy?

Movement exposure therapy gradually reintroduces the activities you fear. The physical therapist works with you to select movements that are appropriate for your health condition. This allows you to compare what you feared with what actually happens, without having to ignore an injury or force a dangerous movement.^{25, 26}

The vicious cycle of avoidance

Avoiding a painful movement can protect a recent injury. If this avoidance persists and goes beyond what is necessary for protection, it can limit activities. The fear-avoidance model describes this potential cycle as follows:¹⁹

1. A fear of movement can cause you to avoid certain actions.
2. A prolonged reduction in physical activity can decrease your strength and your ability to move easily.
3. Reduced capacity may make certain efforts more difficult.
4. These difficulties can intensify fear and avoidance.

How can we break this cycle?

The exhibition is based on steps we’ve chosen together with you:

List the actions you dread. Name the activities you avoid and what you fear, then rank them from least to most worrisome.

You’ll practice a modified movement. The physical therapist will guide you through your first attempt and then adjust the progression based on your response.

You compare your expectations with your experience. A movement may go better than expected, even if some pain remains. This discrepancy can support new learning. The fear-avoidance model describes this process, but it does not prove that there is a single mechanism for every person.^{26, 19}

You apply what you've learned in your daily life. You gradually practice these skills in situations that matter to you.

What do the trials show?

Two trials on chronic back pain help clarify the benefits of exposure:

• In a study involving 44 people, exposure reduced fear of movement and pain-related anxiety more effectively than gradually increasing activity.
• In a trial involving 85 people, both exposure and progressive activity improved performance on the tasks. About half of the participants showed progress that was considered significant, with no clear difference between the two approaches.
• In this second trial, exposure further reduced the highly alarming thoughts about pain and danger associated with the activities.
• The study did not show any clear difference in pain intensity in relation to progressive activity in this trial.^{27, 28}

Why is the therapeutic alliance essential in this treatment?

The therapeutic alliance fosters collaboration between you and your physical therapist through shared goals, a mutual understanding of treatment methods, and a relationship built on trust. A study on chronic back pain found a link between a stronger therapeutic alliance and better outcomes, though it did not prove that this relationship alone was the cause.⁸

What the research tells us

The study by Zimney and colleagues, published online in 2024 and later in a 2025 issue, measured trust, alliance, and outcomes after the first visit and again at the end of the follow-up period:

• The trust and alliance scores were strongly correlated: the correlation coefficients were 0.75 and 0.80, respectively. The closer this measure is to 1, the more the two scores move in tandem.
• Higher relationship scores were also associated with better outcomes in terms of pain, activities, and overall self-reported improvement.
• The measures of trust and alliance were reported by the patients. This study does not allow us to predict an individual outcome based on a score.⁸

The components of a strong therapeutic alliance

You set common goals. You and your physical therapist choose the activities you'd like to be able to do again.

You understand and agree to the treatment methods. The physical therapist explains the recommended treatment and discusses your preferences.

The relationship is based on respect. You can share your questions, concerns, and feedback on the treatment.

Why this is particularly important for psychogenic pain

Some people with unexplained pain have had difficult experiences with their healthcare. In particular, they may report:

• A professional questioned their pain.
• Some comments downplayed their suffering.
• They felt they weren't being taken seriously.

The physical therapist should listen to your experience and acknowledge the reality of your pain. He or she can discuss possible mechanisms without claiming to know the cause, which remains uncertain.⁷

What manual techniques are used to treat psychogenic pain?

Manual techniques may include gentle joint movements and light touch, tailored to your comfort level and with your consent. They can complement the care plan when they provide relief or facilitate movement. Their role depends on the benefits they provide and the other needs of the care plan.

Specific Goals for Manual Therapy

Manual techniques are designed to achieve measurable goals. You can discuss these points with your physical therapist:

• The contact respects your comfort and your consent.
• You can describe pleasant, unpleasant, or unusual sensations.
• The physical therapist checks to see if the movement provides relief.
• Next, try an appropriate activity to see if feeling comfortable makes it easier to move.

Commonly used techniques

Joint mobilization involves moving a joint. The physical therapist performs these movements with their hands, within a range of motion that is comfortable for you. Your comfort and response guide how these techniques are used. Our page on joint mobilization and manipulation explains these techniques.

Gentle pressure is adjusted to suit your tissue and sensitivity. If you report any discomfort, the physical therapist will adjust or stop the technique. Applying stronger pressure is not a goal in itself.

Physical contact is performed with your consent. The physical therapist explains where and why they are placing their hands. You may request an adjustment or decline this contact.

When to Consult a Physiotherapist

A physical therapist who works with people experiencing persistent pain can help you if the pain limits your activities, if you avoid certain movements out of fear, or if previous treatments have been of little help. A functional diagnosis from your doctor can also guide your treatment. You can request a reevaluation if your symptoms change, worsen, or become different, even if your previous test results were normal.⁷

Situations That May Warrant a Consultation

How to Find the Right Physical Therapist

You can ask the physical therapist how he or she meets the following criteria:

• Physical therapists provide care to people with chronic pain or functional disorders.
• The physical therapist takes into account your body, your concerns, and your life circumstances.
• The physical therapist explains the pain in terms you can understand.
• The physical therapist listens to your answers and respects your choices.

At Physioactif, you can discuss your pain, the treatments you’ve already tried, and the activities you’d like to resume. The evaluation allows us to develop a personalized plan for you.

How long does physiotherapy treatment last?

Physical therapy treatment can last several weeks or several months, depending on the goals, the diagnosis, and the progress observed. The durations discussed are not guaranteed recovery times: the 2006 motor imagery program lasted six weeks, while a clinical case involving multiple approaches described 26 visits over nine months.^{23, 22} You and your physical therapist will reassess the need for follow-up as the sessions progress.

Factors Affecting Duration

The history of the pain guides the assessment. The physical therapist takes into account its duration, its progression, and the treatments already tried.

Fear of movement guides your progress. You choose steps that allow you to try out activities without feeling pressured.

Your life circumstances influence the plan. Sleep, stress, anxiety, and everyday challenges may require additional support.

Exercising at home should remain feasible. You choose activities that are suited to your abilities and schedule, and then adjust them based on how you respond.

How should the follow-up steps be organized?

After treatment

The end of the follow-up is determined based on your needs and progress. Some people continue with the strategies on their own; others need occasional appointments or more regular support. The plan can also be adjusted if your symptoms change.⁷

What are the most frequently asked questions about this treatment?

Frequently asked questions about this treatment concern the reality of pain, how it complements psychotherapy, exercises, medications, treatment options, and how they differ from other treatment approaches.

Is psychogenic pain real?

So-called psychogenic pain is real. Pain does not become imaginary simply because a medical test cannot explain it. The brain, the body, and the context all play a role in the experience of pain; the fact that the mechanism is not yet fully understood does not diminish the reality of your suffering.^{16, 10}

Can physical therapy replace psychotherapy?

Physical therapy can complement psychotherapy, but it does not replace it when psychological treatment is indicated. The choice of healthcare professionals and medications depends on your needs and your diagnosis.⁶ For primary chronic pain—that is, persistent pain that cannot be sufficiently explained by another medical condition—the recommendations include, among other things, exercises and certain forms of psychotherapy. Not all patients require the same treatment.⁷

For the nociplastic component, the Fitzcharles review favors non-pharmacological approaches. Treatments that primarily target a local abnormality—such as certain injections or surgeries—are less effective for this component. This does not negate their potential usefulness for another concurrent disease or injury. Medications, including anti-inflammatory drugs and opioids—such as morphine—also require an assessment of their benefits and risks based on the underlying mechanism of pain.³

What exercises are recommended?

The exercises depend on your symptoms and the activities you want to resume. The program may include the following options:

• Breathing and relaxation exercises help you learn ways to relax.
• Tailored movements allow you to resume your activities step by step.
• Imagery exercises help you visualize a movement when they are relevant to the problem being addressed.
• Gradual activities help you work toward specific goals, such as walking or completing a household task.

The type of exercise, its intensity, and its progression all play a role in choosing a program. Strength-training exercises, in particular, can help build the abilities you need for your activities. The physical therapist will tailor the difficulty to your specific situation.

Should I stop taking my medication?

Do not change your medications without discussing it with your doctor. Physical therapy is part of your care plan. If an adjustment is necessary, your doctor will plan it with you, taking into account the benefits, risks, and possible effects of stopping treatment.⁷

How do I know if this is the right treatment for me?

A physical therapy evaluation may be appropriate in the following situations:

• Your pain persists or limits your activities, even though its cause remains unclear.
• You avoid certain movements because they make you anxious.
• You'd like to discuss other ways to manage your symptoms.
• Do you have questions about the mechanisms behind your pain?

The initial consultation allows you to set goals and determine whether additional medical evaluations or other professionals should be involved in your care.

What is the difference from traditional physical therapy?

Treatment for persistent pain may focus on the following aspects, which are also part of other physical therapy programs:

• Education helps you understand pain and the available treatment options.
• Gradual exposure helps you try activities you find daunting.
• Working together allows us to develop a plan that aligns with your goals.
• The treatment addresses your abilities, symptoms, and the factors that affect your daily life.
• Motor imagery may be added when it is appropriate for the diagnosis and the specific difficulties encountered.

References

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