Chronic lower back pain starts off with either an “injury”.  You have felt something in your lower back doing an activity or develops overtime with ongoing load.  Most back issues resolve with treatment and exercise.  The usual time is 6 to 12 weeks as the body heals and puts down scar tissue to repair the injured area.

However, with some people, pain continues on greater than 3 months after the physical tissues have healed.  Why?  And what can be done about it?

What is pain and why do we feel it?

The International Association for the Study of Pain (IASP) defines pain as “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”

Pain is an unpleasant experience that you feel.  It is a normal process of your body.  However there are times when it can linger around for a long time and impacts your daily life and the activities you enjoy.

The big take away from this is pain is not just about physical sensation.  It is influenced by your attitudes, beliefs, personality and social experiences which can then affect your emotional and mental wellbeing. Pain is there to motivate you to take action to protect yourself.

This means is all areas of your life can influence your pain, not just the single physical aspect.

How does back pain become chronic lower back pain?

If you experience pain for a long time (greater than 3 months), your brain, spinal cord and nociceptors (pain sensing receptors in our skin and tissues) can adapt to be hypersensitive to signals and the feeling of pain.

Your nociceptors can become more sensitive and fire more often, even to “normal” sensations.  Additionally, your spinal cord can alter its sensitivity, how many signals get sent up to the brain and even end up with “crossed wires”. This can cause signals to be felt as painful/danger that would normally be felt like normal touch or joint movement.

Finally, your brain’s take up of of information from the spinal cord is filtered through your expectations, past experiences, beliefs, attitudes and emotions, becoming “hypervigilant” to pain.

At this stage, your movement no longer causes harm, however, your fear of pain will cause you to avoid activities that could “potentially” cause harm.  Sadly, this begins to extend to not just movement, but activities you used to love to do in cluding meeting up with people/family you love and enjoying life.  The result is not just a physical injury, but a psychological and social one as well.

What makes chronic pain better or worse?

When you have stressors in our life, such as a hard day at work, financial pressure or other triggers that cause anxiety.  Anxiety triggers your body to release a hormone called cortisol. Cortisol is released at the same time as adrenaline and get you ready for ‘fight and flight’. It is an important survival hormone, but also heightens your pain response and the ‘feeling’ of pain.

More Cortisol is like throwing fire on the pain and making it feel worse. The actual injury has not changed, but the feeling of pain is exacerbated.

It is essential to recognise the events in your life that cause extra stress because they heighten your pain. You can’t control your pain response to the events but you can alter either our exposure of these events such as walking away in a stressful situation or taking time to do some deep breathing during our break at work to reduce the stressors and your cortisol response.

You can also be aware that your heightened response is due to the cortisol response, not because the injury has gotten worse. Just being aware of this reduces your anxiety and fear that we are doing any more damage when you feel more pain.

The opposite is also extremely important. Doing things that you enjoy releases hormones such as endorphins, and being surrounded by loved ones releases more long-term oxytocin hormones which dampen the feeling of pain.

This is like putting water on the fire.

Again, this does not alter the injury but it reduces your feeling of the pain associated with it. Often when you have an injury, you stop doing the things you love.  This has the double effect of causing pain and reducing the stress-reducing hormones that are naturally released when doing things we enjoy. Recommencing doing things that you love is a very important part of pain management and the long-term strategy of managing your injury.

What does the latest evidence say you can do about Chronic lower back pain?

In a recent study, published in the British Journal of Medicine on 31st March 2022, researchers Emma Ho and colleagues discovered that the following have the best effects of managing chronic lower back pain in the long term (> 12 months)

  • Physiotherapy guided exercise program together with learning muscle relaxation techniques and graded exposure to activity work best in pain reduction.  Breaking down the movement into parts was the most effective on reducing pain intensity. Movements should not be avoided, but slowly re-introduced so that they become part of your life once again.
  • Pain education (understanding the process of pain) and guided exercise program worked to reduced fear avoidance and improve physical function
  • Finally, although not part of the study, re-introducing social activities (doing things you love) is extremely important to getting your life back AND directly effecting the feeling and perception of pain

Berry, S (2022) The key to treating lower back pain? A universal approach, The Age, 31st March  2022

Ho E K, Chen L, Simic M, Ashton-James C E, Comachio J, Wang D X M, Hayden J A, Ferreira M L, Ferreira P H (2022) Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis.  British Journal of Medicine, 2022;376:e067718




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