Persistent back pain:
when the pain no longer seems to make sense
Persistent back pain can affect almost every part of everyday life
You may find yourself thinking before you bend, lift, climb the stairs, sit for too long or get out of bed. Activities you used to do without a second thought can start to feel risky. Work, exercise, hobbies, travel or simply keeping up with everyday life may gradually become more difficult.
And when the pain goes on for months or years, it is understandable to wonder what’s been missed, or whether this is simply how things are going to be from now on.
There are many reasons why back pain can persist
It does not always start with an injury
Sometimes there is a clear beginning: an accident, an injury, a painful movement or an operation. But persistent back pain can also develop gradually, come and go over many years, or appear without one obvious event that explains why it started.
Most importantly, the amount of pain you experience doesn’t always give us a straightforward measure of what’s happening in the tissues.
Sometimes treatment helps, but the pain comes back
You may already have tried physiotherapy, medication, injections, manual treatment, exercise programmes or other approaches.
Perhaps something helped for a while, or perhaps nothing made much difference. Or maybe you were improving until the pain flared again and you became afraid you had damaged your back all over again.
When pain keeps returning, it’s very easy to become more watchful of your body and increasingly cautious about what you do.
Sometimes there seems to be no clear explanation
You may have had scans or investigations that found little to explain the severity of your pain. And that can be reassuring medically, but so frustrating when you’re still hurting.
Being told that your scan is ‘fine’ does not make the pain disappear. The question becomes: if ongoing damage doesn’t explain this, what else might be keeping the pain going?
What if my scan does show something?
A finding can be real without explaining the whole pain experience
Disc degeneration, disc bulges and other changes in the spine are common, particularly as we get older. Some findings are clinically important and absolutely need appropriate medical care.
Research has also found many degenerative spinal changes in people who have no back pain at all. This means a finding needs to be understood alongside your medical assessment, your history and — importantly — how your pain actually behaves.
WHAT SCIENCE SAYS
Disc degeneration was estimated in 37% of people without back pain at age 20, 52% at age 30 and 68% at age 40.
Brinjikji et al., American Journal of Neuroradiology, 2015
Scans are not a pain meter. Two people can have similar-looking scans and very different experiences of pain. So the question is not simply:
‘Is there something on my scan?’ It’s also:
‘Does that finding explain the whole pattern of pain I am experiencing?’
From the blog: Why your scan findings might not be the whole story →
Sometimes the biggest clues are in how your back pain behaves
Pain that is being significantly influenced by the brain and nervous system often leaves clues. You might notice that:
✓ the pain changes considerably from one day to another
✓ a movement hurts badly sometimes but not at others
✓ your back begins to tense or brace before you have even moved
✓ you expect certain activities to cause a flare
✓ symptoms can begin before, during or several hours after an activity
✓ pain changes depending on stress, attention, sleep or what’s happening around you
✓ there are occasional times when you do far more than expected without the consequences you feared
✓ you feel better when absorbed in something or when your attention is elsewhere
✓ the pain seems much greater than your current physical findings would suggest.
None of these things proves that pain is neuroplastic. And they don’t mean that physical factors are irrelevant. But taken together, patterns like these can give us useful information about whether the brain and nervous system may be contributing to the persistence or amplification of pain.
When protection keeps going
Pain is designed to protect us
Pain is part of the body’s protective system. When something is injured or potentially under threat, pain can be extremely useful: it changes our behaviour and encourages us to protect ourselves.
But the protective system can sometimes remain highly responsive even when the level of protection is no longer matched by what is happening in the tissues. Pain can also become associated with movements, positions or situations that the brain has learned to expect will hurt.
Gradually, the nervous system can become very good at preparing for pain. But that doesn’t make the pain imaginary: it means that something which began as protection may have become overprotective.
The good news is that learned responses can change
The brain continually updates through experience. If your back has become associated with danger, reassurance alone may not be enough. You can understand intellectually that a movement is safe while your body still braces as though it isn’t.
How I work with persistent back pain
Pain Reprocessing Therapy is at the heart of my approach
Pain Reprocessing Therapy gives us a framework for reducing fear around pain and helping the brain respond differently to sensations and movement.
But I don’t work from one method alone. Depending on what seems to be contributing to your individual pain pattern, I may also draw on clinical hypnosis and imagery, CBT, ACT and mindfulness. These are used alongside PRT to help with things such as attention, expectations, high-alert responses, fear of movement and rebuilding confidence in your body.
This is not about ignoring pain, pushing through it or trying to convince yourself that nothing is wrong. We look carefully at what happens in your own body and use that information to guide the work.
What the Boulder Back Pain Study found
The best-known PRT trial, which is often called the Boulder Back Pain Study — involved 151 adults with primary chronic back pain of low-to-moderate severity.
After four weeks of treatment, 66% of participants receiving PRT were pain-free or nearly pain-free, compared with 20% receiving placebo and 10% receiving usual care. Benefits were largely maintained at one year.
At five-year follow-up, participants originally allocated to PRT continued to report significantly lower pain than those originally allocated to placebo or usual care; among the 38 PRT participants who completed the follow-up, 55% were nearly or completely pain-free. The researchers also emphasise that the original trial involved low-to-moderate chronic back pain, so we shouldn’t assume the same results for every person with persistent back pain.
Ashar et al., JAMA Psychiatry, 2022; five-year follow-up, 2025
Getting back to movement
Knowing your back is safe and trusting it are not always the same thing
Persistent pain can gradually change the way you move. You may brace before bending, avoid lifting, use the stairs differently or stop activities because you are worried about what will happen afterwards. That caution makes complete sense when movement has repeatedly been followed by pain.
But when a movement or activity has been medically assessed as safe, continually avoiding it can also mean that the nervous system never gets the chance to discover that things may have changed.
We start with what matters to you
The goal will be different for everyone. It might be moving more freely around the house, walking further, lifting and carrying, returning to work, exercising again, travelling, gardening, getting back to a sport or simply being able to bend without thinking about your back first.
We can gradually test what your body can do through carefully chosen experiences rather than forcing movement or trying to ignore pain: the aim is to rebuild confidence through evidence.
Where hypnosis and mental rehearsal can help
Sometimes I use clinical hypnosis, imagery or mental rehearsal as part of this process. If a particular movement or activity has become strongly associated with pain or danger, we can first rehearse it in imagination, practising movement with less tension, fear and anticipation, before gradually testing it in real life.
Hypnosis is never compulsory: visualisation and other forms of mental rehearsal can be used instead.
What if Ive had back surgery?
Persistent pain after surgery deserves proper assessment
Back surgery can be necessary and effective when there is a clear structural problem that surgery can address. If pain persists following an operation, that does not automatically mean that the pain is neuroplastic or that the surgery was unnecessary. There are physical reasons why pain can continue after surgery, and these need appropriate medical assessment.
But sometimes the operation has addressed the structural problem and the pain still doesn’t settle as expected. Where further medical assessment does not identify an ongoing problem that adequately explains the pain, it may be useful to consider whether an overprotective brain and nervous system are now contributing to the picture.
Could this approach be relevant to you?
Medical assessment comes first
I do not diagnose the cause of back pain or replace medical investigation. Before we work together, I would want you to have had appropriate medical assessment, particularly if your pain is new, changing, has not previously been investigated, or there are symptoms that may require further medical attention.
If anything in your presentation suggested that further medical assessment was needed, I would ask you to return to an appropriate healthcare professional.
This work may be worth exploring when:
✓ your pain has persisted or repeatedly returned despite treatment;
✓ the current physical findings do not seem to explain the whole pain experience;
✓ you have been medically reassured about movement but still find yourself frightened, bracing or avoiding activity;
✓ the way your pain changes provides clues that neuroplastic processes may be contributing;
We look at the overall picture. We begin by considering your medical history, what you’ve already tried and how your pain behaves now.
The aim is not simply to live your life around your pain
Persistent pain can make life smaller without you even noticing it happening. This work is about understanding why your system may still be protecting you, testing that understanding carefully and gradually rebuilding trust in what your body can do.
If you would like to talk through what has been happening and whether this approach could be relevant to you, we can start with a free introductory call.