Rethinking Chronic Low Back Pain
Why It Persists, and What Actually Helps
Chronic low back pain carries 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, and the subtle fear that one wrong movement could “throw your back out” again.
Over time, something deeper can happen. Trust in your body begins to erode.
Practitioners see this erosion too. It appears in guarded movement, reduced confidence, and the quiet statement, “I’ve tried everything.”
The question is not always, “What is wrong with the spine?” A better question may be, “What is keeping the pain cycle going?”
Chronic low back pain is not necessarily evidence of continuing tissue damage. Pain may persist because several mechanical, neurological, physical, and psychological factors begin reinforcing one another.
Understanding those factors is where a different path forward begins.
This retains the emotional strength of the original, improves accessibility, and introduces the integrated model without diminishing the possible importance of structural findings.
What Chronic Really Means
When low back pain persists for three months or longer, it is classified as chronic. But chronic does not mean permanent, nor does it necessarily mean that tissues are continuing to deteriorate.
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 that structure alone does not usually explain why pain persists.
Chronic low back pain may be influenced by an interaction between:
Physical capacity and mechanical demands
Nervous system sensitivity
Sleep and recovery
Stress physiology
Inflammation and metabolic health
Beliefs and fears about movement
Think of these factors as parts of a feedback loop rather than evidence of one unresolved injury.
For practitioners, this is where systems thinking becomes essential. For people living with chronic pain, understanding that the system can change is where hope begins.
The Six Forces That Keep Back Pain Alive
Physical capacity and mechanical demands
The lumbar spine is built to move and bear load. Problems can develop when the demands placed on the body exceed its current strength, mobility, endurance, or coordination.
Limited movement through the hips or thoracic spine may change how forces are distributed. Reduced trunk and hip endurance can make lifting, carrying, sitting, or prolonged activity increasingly difficult. This does not necessarily indicate continuing structural damage. It may reflect a gap between what the body is being asked to do and what it is currently prepared to tolerate.
The answer is usually not long-term avoidance, but progressive reconditioning.
Walking, mobility work, trunk endurance training, and gradual resistance exercise can rebuild capacity. Manual therapy may support this process by reducing pain and improving movement where restrictions are identified.
The goal is to expand what the body can tolerate without overwhelming it.
Capacity before intensity.
Nervous system sensitivity
For some people with chronic pain, the nervous system becomes increasingly sensitive. Signals that were once tolerated may begin to produce a stronger pain response. The body’s protective alarm has become easier to trigger.
This may help explain why pain intensity and imaging findings do not always match. It does not mean the pain is imaginary. It means that pain reflects both information arriving from the tissues and how the nervous system interprets that information.
Progressive movement, strength training, cardiovascular exercise, balance work, breathing practices, and mindfulness may help reduce threat and rebuild tolerance. Repeated experiences of safe, successful movement give the nervous system new information.
Manual therapy may also reduce symptoms and protective guarding through mechanical and sensory input, helping some patients move with greater comfort and confidence.
The nervous system is adaptable. Sensitivity can change.
Sleep and recovery
Ask someone living with chronic back pain how they sleep. The pause before they answer often tells you a great deal.
Pain can disturb sleep, and poor sleep can increase pain sensitivity, fatigue, emotional distress, and difficulty functioning. Over time, the two can reinforce one another.
You can prescribe a thoughtful exercise program and provide skilled manual therapy, but progress may be harder to sustain when sleep remains severely disrupted.
Sleep is not a minor lifestyle detail. It is part of the biological environment in which recovery and adaptation occur. It should be assessed and addressed alongside movement, treatment, and exercise.
Protect sleep, and you strengthen the foundation for recovery.
Stress physiology
Pain and stress are not separate experiences. They share neurological, hormonal, emotional, and behavioural pathways.
Persistent stress can increase vigilance, muscular tension, sleep disruption, and sensitivity to pain. Pain can then become another source of stress, creating a cycle that keeps the body feeling guarded and under threat.
Breathing often changes during stress, becoming faster, shallower, or less comfortable. Slow, controlled breathing, sometimes using a slightly longer exhalation, may reduce arousal and help the body shift toward a calmer state.
Breathing practices do not remove the physical contributors to back pain. They provide another way to influence tension, attention, and nervous-system regulation.
Sometimes the first sign of progress is simply discovering that the body does not have to remain on constant alert.
Inflammation and metabolic health
Chronic pain is influenced by the body’s broader biological environment. Poor sleep, inactivity, smoking, excessive alcohol consumption, metabolic dysfunction, and excess visceral fat may contribute to systemic inflammation and are associated with poorer musculoskeletal health.
This is not about appearance or blaming people for their pain. It is about recognizing that metabolic health, physical conditioning, and mechanical capacity are interconnected.
Nutrition does not replace rehabilitation. A balanced dietary pattern, adequate protein, regular activity, restorative sleep, and improved metabolic health can support recovery, muscle development, and general health.
Body weight is only one part of the picture. What matters clinically is the relationship between the demands placed on the body and its capacity to meet them.
Improve the biological environment, rebuild capacity, and the system may become more adaptable.
Beliefs and fears about movement
One of the most easily overlooked influences on chronic low back pain is what a person believes about their spine.
If someone sees the back as fragile or damaged, movement may feel dangerous. They may begin avoiding bending, lifting, exercise, or other meaningful activities. Over time, reduced exposure can lower conditioning and reinforce the expectation that movement will cause harm.
This is not weakness. It is a protective response.
Fear of movement can contribute to disability, particularly when it leads to persistent avoidance. Changing this pattern does not mean denying the pain or telling someone to push through it. It means providing a more accurate understanding of pain and gradually rebuilding confidence through achievable movement.
The spine is strong, adaptable, and capable of increasing its tolerance. Every successful movement experience can provide evidence that the body is more capable than fear suggests.
Change the understanding, and the response can begin to change.
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.
Further Exploration in Trajectory
These principles are explored more deeply in my forthcoming book, Trajectory: The Power of Everyday Choices. Chapter 3 examines how physical capacity, nervous system sensitivity, sleep, stress, metabolic health, and beliefs about movement can interact in persistent pain. It places rehabilitation within a broader process of adaptation, showing how everyday choices can gradually build greater capacity, confidence, and resilience.
Publication is planned for 2027.
References
Brinjikji, W., Luetmer, P. H., Comstock, B., et al. (2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. American Journal of Neuroradiology, 36(4), 811-816.
Foster, N. E., Anema, J. R., Cherkin, D., et al. (2018). Prevention and treatment of low back pain: Evidence, challenges, and promising directions. The Lancet, 391(10137), 2368-2383.
GBD 2021 Low Back Pain Collaborators. (2023). Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: A systematic analysis of the Global Burden of Disease Study 2021. The Lancet Rheumatology, 5(6), e316-e329.
George, S. Z., Fritz, J. M., Silfies, S. P., et al. (2021). Interventions for the management of acute and chronic low back pain: Revision 2021. Journal of Orthopaedic & Sports Physical Therapy, 51(11), CPG1-CPG60.
Hayden, J. A., Ellis, J., Ogilvie, R., Malmivaara, A., & van Tulder, M. W. (2021). Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews, 2021(9), CD009790.
Rubinstein, S. M., de Zoete, A., van Middelkoop, M., Assendelft, W. J., de Boer, M. R., & van Tulder, M. W. (2019). Benefits and harms of spinal manipulative therapy for the treatment of chronic low back pain: Systematic review and meta-analysis of randomised controlled trials. BMJ, 364, l689.
Runge, N., Ahmed, I., Saueressig, T., et al. (2024). The bidirectional relationship between sleep problems and chronic musculoskeletal pain: A systematic review with meta-analysis. Pain, 165(11), 2455-2467.
Schuttert, I., Timmerman, H., Petersen, K. K., et al. (2021). The definition, assessment, and prevalence of human-assumed central sensitisation in patients with chronic low back pain: A systematic review. Journal of Clinical Medicine, 10(24), 5931.
Wertli, M. M., Rasmussen-Barr, E., Weiser, S., Bachmann, L. M., & Brunner, F. (2014). The role of fear-avoidance beliefs as a prognostic factor for outcome in patients with nonspecific low back pain: A systematic review. The Spine Journal, 14(5), 816-836.e4.
Woolf, C. J. (2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain, 152(3 Suppl), S2-S15.
World Health Organization. (2023). WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. World Health Organization.
Zaccaro, A., Piarulli, A., Laurino, M., et al. (2018). How breath-control can change your life: A systematic review on psychophysiological correlates of slow breathing. Frontiers in Human Neuroscience, 12, 353.
DR. BRIAN ABELSON, DC. - The Author
Dr. Brian Abelson is a chiropractor, author, and educator with more than 30 years of clinical experience in musculoskeletal care, rehabilitation, and sports performance. His educational work focuses on musculoskeletal conditions, human movement, sports biomechanics, and evidence-informed approaches to treatment and rehabilitation.
He is the developer of Motion Specific Release (MSR) and Clinical Director of Kinetic Health in Calgary, Alberta, Canada.
Continue Learning with MSR Courses and MSR Pro
For Healthcare Practitioners
Motion Specific Release integrates assessment, clinical reasoning, manual therapy, exercise, and patient education within one adaptable approach to musculoskeletal care.
MSR Pro and MSR courses support different parts of that learning process:
Structured Clinical Education: MSR courses connect applied anatomy and biomechanics with orthopedic and neurological assessment, myofascial procedures, fascial expansions, joint mobilization, manipulation, and rehabilitation.
Hands-On Skill Development: Live training provides opportunities to refine palpation, patient positioning, force application, and clinical decision-making through practice and direct feedback.
MSR Pro Clinical Library: Members receive access to more than 200 MSR procedures, downloadable and fillable clinical forms, examination resources, rehabilitation progressions, and exercise-prescription materials.
Extensive Video Resources: More than 800 videos support examination, treatment procedures, exercise rehabilitation, and clinical application.
Patient Education: A library of 50 condition articles helps practitioners explain common musculoskeletal problems and provide patients with practical information.
Continued Development: Resources are updated as MSR courses and clinical education continue to evolve.
Videos and articles can introduce concepts, but hands-on proficiency develops through deliberate practice, feedback, and experience. MSR is designed to help practitioners connect technique with clinical reasoning and adapt care to the individual rather than apply the same protocol to everyone.
Explore MSR Pro | View Online and Live Courses
Disclaimer:
The content on the MSR website, including articles and embedded videos, is provided for educational and informational purposes only and is not a substitute for individualized medical advice, diagnosis, or treatment. MSR techniques require appropriate professional training; do not attempt or apply these procedures unless you are properly trained and licensed where applicable. By accessing this content, you assume full responsibility for your use of the information, and to the fullest extent permitted by law, the authors and contributors disclaim liability for any loss, injury, or damages arising from its use.
This website does not establish a healthcare provider–patient relationship. If you have a medical concern, consult a qualified, licensed healthcare professional. This website is intended for adults and is not directed to individuals under 18. The MSR website may include links to third-party sites; we do not control and are not responsible for the content, accuracy, or practices of external websites.
By using this website, you agree to indemnify and hold harmless the authors and contributors from any claims, liabilities, and legal fees arising from your use of the site or violation of these terms. For more information, please review the full disclaimer and policies on this website.
Comments