Rethinking Chronic Low Back Pain
- Dr. Brian Abelson
- 3 days ago
- 11 min read
Updated: 1 day ago
Why It Persists, and What Actually Helps
Chronic low back pain has a particular psychological weight.
It is not just discomfort. It is the hesitation before tying your shoes. The mental calculation before picking up a grandchild. The subtle fear that one wrong move could “throw it out” again.
Over time, something deeper happens. Trust in your body erodes.
For practitioners, this erosion is just as visible. You see it in posture, guarded movement, flattened affect, and in the quiet sentence, “I’ve tried everything.”
The question is rarely, “What is wrong with the spine?”The better question is, “What is keeping the system stuck?”
Chronic low back pain is often less about damage and more about persistence. And persistence has drivers.
What Chronic Really Means
When pain lasts longer than 3 months, we label it chronic. But duration alone tells us very little.
Large imaging studies show that disc bulges and degenerative changes are common in people without pain (Brinjikji et al., 2015). This does not mean structure is irrelevant. It means structure alone rarely explains why pain remains.
Chronic low back pain is often maintained by an interaction between:
Mechanical load tolerance
Nervous system sensitivity
Sleep quality
Stress physiology
Inflammatory load
Beliefs about movement
Think of it as a feedback loop rather than a single injury.
For clinicians, this is where systems thinking becomes essential. For patients, this is where hope begins.
The Six Forces That Keep Back Pain Alive
Load Intolerance
The lumbar spine is designed to move and bear load, but capacity declines when movement becomes restricted or strength and endurance wane.
Stiff hips increase lumbar strain. Reduced trunk endurance compromises stability under fatigue. Prolonged sitting decreases tissue resilience and alters coordination. Over time, the spine compensates for what other regions are not contributing, and even simple tasks begin to feel provocative.
This is often not structural damage. It is load intolerance.
The solution is not avoidance, but progressive reconditioning.
Walking progression, controlled mobility, trunk endurance training, and gradual resistance restore capacity. Manual therapy can further improve load tolerance by addressing the broader kinetic chain. Restrictions in the hips, thoracic spine, sacroiliac joints, or surrounding soft tissues alter the distribution of forces. Targeted joint and soft tissue treatment helps normalize motion and reduce compensatory strain.
When load is redistributed efficiently and capacity is rebuilt, the system becomes less reactive.
Capacity before intensity.
A Sensitive Nervous System
Chronic pain frequently involves central sensitization, a state in which the nervous system amplifies input and lowers the pain threshold (Woolf, 2011). In simple terms, the alarm system becomes overly reactive.
This helps explain why imaging findings may appear mild while pain feels intense. The issue is not always tissue damage, but heightened neural responsiveness.
The goal is not to suppress the alarm aggressively, but to retrain it.
Proper, progressive training, strength, cardiovascular conditioning, balance and proprioceptive work, breath regulation, and mindfulness practices all influence neuroplasticity. The nervous system is adaptable. Repeated, safe movement experiences literally reshape neural pathways, increasing tolerance and recalibrating threat perception.
Manual therapy also plays a role. Myofascial release, joint mobilization, and Traditional Chinese Medicine approaches provide novel sensory input that can modulate afferent signalling, reduce protective guarding, and help normalize pain processing.
When applied thoughtfully and consistently, these inputs teach the system safety again.
Sleep, The Hidden Variable
Ask someone living with chronic back pain how they sleep. The pause before they answer often tells you everything.
Broken sleep increases inflammatory signalling and lowers pain thresholds (Irwin, 2019). Deep sleep is when growth hormone is released, tissues repair, immune balance stabilizes, and the nervous system recalibrates its sensitivity.
When sleep is fragmented, the body remains in a reactive state. Muscles stay guarded. Pain signals amplify. Recovery stalls.
You can prescribe the perfect exercise program, deliver precise manual therapy, and optimize biomechanics, but without adequate sleep, those gains struggle to consolidate.
Sleep is not a secondary lifestyle variable. It is a primary biological driver of adaptation.
Protect it, and recovery accelerates. Ignore it, and progress becomes fragile.
Stress Physiology and Breath Patterns
Chronic stress keeps the nervous system biased toward survival mode. Sympathetic tone rises. Cortisol remains elevated. Muscles stay subtly contracted, even at rest. Over time, this persistent state of vigilance amplifies pain sensitivity and slows tissue recovery.
Breathing patterns often mirror this physiology. Instead of quiet diaphragmatic expansion, breathing becomes shallow and chest-dominant. The scalenes, upper trapezius, and accessory respiratory muscles overwork. Tension accumulates. Mechanical load increases through the cervical and thoracolumbar regions. The body remains on alert.
Pain and stress are not separate systems. They share neural pathways and regulatory circuits.
Slow diaphragmatic breathing, roughly 5 to 6 breaths per minute with a slightly longer exhale, helps shift autonomic balance toward parasympathetic dominance (Jerath et al., 2006). In practical terms, it lowers baseline arousal, reduces muscle guarding, and recalibrates the body’s threat response.
When patients experience this shift, even briefly, they often recognize something important: the body can move from protection toward regulation. And regulation is the gateway to healing.
Inflammatory Load
Pain does not exist in isolation from the body’s internal chemistry. When systemic inflammation rises, pain thresholds fall.
Highly processed foods, excess refined sugar, inactivity, poor sleep, chronic stress, and excess alcohol all elevate pro-inflammatory cytokine levels (Chrousos, 2009). Increased adipose tissue, particularly visceral fat, is also metabolically active. It releases inflammatory mediators such as interleukin-6 and tumour necrosis factor-alpha, which can amplify pain sensitivity and impair tissue recovery.
This is not about appearance. It is about physiology.
Excess body weight also increases mechanical demand on the spine. Greater compressive load, combined with reduced conditioning, can lower tolerance to daily activities. The issue is not simply mass. It is a load relative to capacity.
Nutrition does not replace rehabilitation, but it strongly influences how well rehabilitation works. Adequate protein, omega-3–rich foods, phytonutrient-dense vegetables, stable blood sugar, and gradual conditioning reduce inflammatory signalling and improve metabolic efficiency.
Even modest improvements in body composition and conditioning can significantly improve load tolerance and pain regulation.
Lower the inflammatory background, increase capacity, and the system becomes more adaptable.
Fear and Narrative
One of the most underestimated drivers of chronic low back pain is belief.
If someone views their spine as fragile or “damaged,” movement becomes guarded. Guarded movement reduces load exposure. Reduced exposure lowers conditioning. Lower conditioning increases sensitivity. The cycle reinforces itself.
This is not a weakness. It is protective physiology.
Research shows that fear-avoidant behaviours are among the strongest predictors of long-term disability in chronic pain, often more predictive than imaging findings themselves (Turk et al., 2011).
The brain constantly evaluates threat. When a movement is interpreted as dangerous, muscle tension increases, breathing shifts, and pain signaling amplifies. The body behaves according to the narrative it has adopted.
Changing the story does not mean denying pain. It means updating the interpretation.
When people understand that the spine is strong, adaptable, and capable of progressive loading, physiology shifts. Confidence reduces guarding. Exposure rebuilds tolerance. The alarm quiets.
Change the narrative, and you change the neural response.
The Integrated Approach - Chronic Low Back Pain
Calm. Restore. Build.
Chronic low back pain rarely resolves through a single intervention. It improves when multiple systems are addressed together, with the emphasis shifting as the body adapts.
Recovery is staged but integrated from the beginning.
Manual therapy, exercise, breathing regulation, mindfulness, sleep optimization, and dietary considerations are not separate tracks. They are coordinated inputs. The exact combination varies depending on the individual’s irritability, conditioning, metabolic state, and psychological readiness.
Phase 1: Calm the System
When irritability is high, the nervous system is protective. Muscles guard. Pain thresholds drop. Recovery slows.
From the very first phase, care is integrated.
Manual therapy may be used to reduce protective tone, improve joint mechanics, and normalize afferent signalling. Gentle, pain-tolerant movement begins immediately, often through walking or low-load mobility. Breathwork and mindfulness practices are introduced to downshift sympathetic dominance. Sleep hygiene and basic nutritional guidance help reduce inflammatory load.
The intensity is modest. The coordination is deliberate.
The goal is regulation, not exhaustion.
When pain shifts from constant and unpredictable to intermittent and manageable, the system is recalibrating.
Phase 2: Restore Motion and Control
As sensitivity decreases, the emphasis shifts toward capacity.
Manual therapy continues where mechanical restrictions persist, addressing joint and soft-tissue limitations throughout the broader kinetic chain. Exercise becomes more specific, targeting hip mobility, thoracic motion, trunk endurance, and proprioceptive control. Cardiovascular conditioning improves circulation and metabolic resilience.
Breathing practice continues, now reinforcing movement efficiency rather than just calming reactivity. Nutritional strategies support tissue repair and stable energy availability.
Everything works together.
Here, we are not only reducing pain. We are rebuilding coordination.
Phase 3: Build Resilience
Once tolerance improves, the load is increased strategically.
Progressive resistance training restores real-world capacity. Functional lifting, carrying, and balance training improve force transfer and adaptability. Manual therapy becomes less frequent, used selectively to maintain mobility or address emerging restrictions.
Breath regulation and mindfulness now enhance performance and recovery. Nutritional considerations support muscle synthesis, metabolic efficiency, and the control of inflammation.
Flare-ups may occur. The response is measured, temporary load adjustment, not retreat.
The objective is confidence under load.
The Foundation Beneath Every Phase
Across every stage of recovery, two regulators remain constant: sleep and breath.
Deep sleep is when growth hormone is released, inflammatory signalling is reduced, immune function recalibrates, and pain-processing centers in the brain reset. Without adequate slow-wave sleep, tissues repair more slowly, sensitivity remains elevated, and adaptation is incomplete.
Breathing governs autonomic tone. It influences heart rate variability, muscle tension, stress hormone output, and threat perception. A regulated breath pattern helps shift the nervous system out of persistent vigilance and into recovery mode.
These are not lifestyle add-ons introduced later in care. They are biological prerequisites for adaptation.
As rehabilitation progresses, the emphasis on mobility, strength, or conditioning may change. But sleep quality and autonomic regulation remain foundational.
Calm. Restore. Build.
Not isolated interventions, but coordinated phases within a system that is capable of change when its foundations are supported.
Conclusion
Chronic low back pain is rarely a single problem with a single solution. It is often the result of multiple systems interacting over time, such as mechanical load, nervous system sensitivity, recovery biology, stress physiology, inflammation, and belief patterns. When we address only one piece, progress can feel temporary. When we address the pattern, adaptation becomes sustainable.
For patients, this means your spine is not fragile, and your pain is not random. Your system is responsive. For practitioners, it reinforces that technique alone is rarely enough. Integration matters. Sequencing matters. Regulation matters. When load is rebuilt gradually, the nervous system is retrained, sleep is protected, inflammation is reduced, and fear is reframed; something deeper happens. Trust returns.
Calm the system. Restore capacity. Build resilience.
The body is capable of change when we support it as a whole.
Trajectory
Many of the principles discussed in this article are explored in greater depth in my forthcoming book, Trajectory. Chapter 3 expands on the concept that chronic pain is rarely just structural. It examines how load intolerance, nervous system sensitization, sleep disruption, stress physiology, inflammatory signalling, and belief patterns interact to influence long-term musculoskeletal health.
Rather than isolating the spine as the problem, Trajectory presents an integrated model of adaptation, one that connects biomechanics, autonomic regulation, metabolic health, and neuroplasticity. The book outlines how graded movement, strength training, breath regulation, sleep optimization, and lifestyle alignment reshape pain processing and restore resilience over time.
Scheduled for release in late 2026 or early 2027, Trajectory bridges neuroscience and physiology with practical application. It reframes rehabilitation not as symptom suppression, but as a process of recalibrating the system so that capacity exceeds threat.
References
Brinjikji W, Luetmer PH, Comstock B, Bresnahan BW, Chen LE, Deyo RA, et al. Imaging features of spinal degeneration in asymptomatic populations: A systematic review and meta-analysis. American Journal of Neuroradiology. 2015;36(4):811–816.
Chrousos GP. Stress and disorders of the stress system. Nature Reviews Endocrinology. 2009;5(7):374–381.
Foster NE, Anema JR, Cherkin D, Chou R, Cohen SP, Gross DP, et al. Prevention and treatment of low back pain: Evidence, challenges, and promising directions. The Lancet. 2018;391(10137):2368–2383.
Irwin MR. Sleep and inflammation: Partners in sickness and in health. Nature Reviews Immunology. 2019;19(11):702–715.
Jerath R, Edry JW, Barnes VA, Jerath V. Physiology of long pranayamic breathing: Neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system. Medical Hypotheses. 2006;67(3):566–571.
Turk DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Clinical Journal of Pain. 2011;27(6):509–517.
Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2011;152(3 Suppl):S2–S15.
DR. BRIAN ABELSON, DC. - The Author
With over 30 years of clinical experience and more than 25,000 patients treated, Dr. Brian J. Abelson is the creator of Motion Specific Release (MSR), a multidisciplinary assessment and treatment system that integrates biomechanics, fascia science, neurology, manual therapy, exercise rehabilitation, and acupuncture. He is an internationally recognized best-selling author of 10 books and 200+ articles, and has trained healthcare professionals through structured MSR courses and clinical education programs throughout Canada and the United States. Dr. Abelson practices at Kinetic Health in Calgary, Alberta, and continues to develop educational resources focused on long-term function, resilience, and the health trajectory shaped by everyday choices.
For patients, his goal is simple, reduce pain, restore movement, and build long-term independence. For practitioners, MSR provides a practical framework you can integrate directly into daily clinical care.
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Elevate your clinical practice with Motion Specific Release (MSR) training and MSR Pro, a comprehensive, evidence-informed approach to musculoskeletal assessment and treatment designed to improve diagnostic precision, hands-on skill, and patient outcomes.
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Proven Clinical SystemDeveloped by Dr. Brian J. Abelson, DC, with over 30 years of clinical experience and more than 25,000 patients treated, MSR integrates the most effective components of osseous and myofascial therapies into a cohesive, repeatable framework. The system is grounded in clinical logic and supported by patient outcomes, with a clinic success rate exceeding 90% in decreasing pain and improving function.
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A System Built for GrowthMSR is designed to help practitioners think clearly in complex presentations, develop adaptable strategies, and evolve as clinicians. This approach aligns with the broader Trajectory principle, better outcomes are built through the cumulative power of consistent, high-quality clinical decisions.
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