When pain keeps coming back, or never quite goes away for months, years, or even decades, how do you respond?
Are you someone who becomes cautious, avoiding certain activities because you’re worried they’ll hurt? Or are you the person who pushes through, determined to carry on regardless?
Perhaps you’re a mixture of the two. You might step back from certain parts of life while forcing yourself through others.
The avoider and the pusher-through
The avoider may gradually begin doing less. Perhaps you’ve stopped going out for longer walks, avoided travelling or social gatherings, or stepped back from hobbies you used to love. You might find yourself thinking, ‘I’d better not. What if it makes things worse?’
Over time, frustration can give way to resignation. You begin arranging your life around pain. Scans and tests may come back completely normal, leaving you confused as to why you’re still hurting. Or they might show things like disc bulges or degeneration — labels that can create a powerful fear that you’re physically ‘broken’, even though these findings are common in people with no pain at all. Either way, you’re left stuck.
Living with persistent pain can become an exhausting rollercoaster of hope and disappointment.
The pusher-through responds quite differently. You’re determined not to let pain dictate your life. You’re active, independent, someone who gets on with things. Perhaps there’s even a sense of, ‘I’m not going to become that person. That’s not me.’
You don’t want to give up the things you love, or be seen as weak, fragile or somebody who can’t cope. So you keep going, sometimes forcing your way through activities despite the discomfort. You might ignore symptoms, tell yourself to stop making a fuss, all while expecting that you’ll pay for it afterwards.
Pushing through can be a way of protecting ourselves too — not necessarily from the activity itself, but from acknowledging a vulnerability we’d rather not face.
Of course, these aren’t fixed personality types. I recognise elements of both in my own experience of persistent back pain. There were times when I tried to force my way through daily life, and others when pain made me reluctant to leave the house at all.
And while resting or persisting can sometimes be appropriate, the question is whether we’re making a conscious choice or simply following an automatic pattern.
Interestingly, this distinction has been explored in pain research. Hasenbring and Verbunt describe an avoidance–endurance model, recognising that some people respond to pain by withdrawing from activity, while others persist despite it. Both responses can become unhelpful when pain has persisted for a long time.
Why our expectations of pain matter
Pain is a protective experience, but it isn’t simply a readout of what’s happening in our tissues.
The International Association for the Study of Pain (IASP) recognises that pain is a personal sensory and emotional experience influenced by biological, psychological and social factors.
Alongside information coming from the body, our memories, emotions, attention and expectations can all influence how much pain we feel. Our brain and nervous system are continually learning from experience and anticipating what might happen next.
If an activity has repeatedly been painful, your nervous system may begin expecting pain before you’ve even started. If going for a walk has often been followed by a flare-up, that anticipation starts influencing how you approach your next walk — amplifying pain, increasing apprehension, and reinforcing what you expect.
For the avoider, the more an activity is avoided, the more threatening it feels. Without opportunities to discover that engaging in life can be safe, the original expectation goes unchallenged.
For the pusher-through, repeatedly pushing beyond comfortable limits leads to flare-ups, reinforcing the belief that pain is simply the price you must pay for staying active.
These patterns help explain how our automatic responses can contribute to keeping the experience going — regardless of whether there was ever a specific injury in the first place.
Knowing you’re safe and feeling safe aren’t always the same thing.
Whether you tend to avoid activities or force your way through them, the underlying driver is often the same: an automatic prediction of danger operating beneath conscious control.
Think about standing at one end of a high footbridge. You can see it’s structurally sound, and everyone else is crossing happily. You reason with yourself that it’s perfectly safe.
Yet your legs begin to shake. Your stomach tightens, your heart races and you begin to feel sick. Knowing you’re safe and feeling safe aren’t the same thing.
Something similar can happen when living with long-term back pain. Physical reassurance and medical clearance don’t automatically mean your nervous system feels safe when you engage with your life — whether that’s going for a walk in the local park, planning a weekend trip, spending an afternoon gardening, or simply saying yes to a social evening out.
The subtle ways we prepare for trouble
We are constantly immersed in our environment, responding to what’s happening around us without realising it.
Imagine your phone pings with an unexpected message or an aggressive email. You may notice your shoulders tightening, your breathing changing or your heart rate rising. Your body has responded physically to something that hasn’t physically touched you.
Our internal monologue works the same way: ‘Oh no, here we go again. When is this ever going to stop?’ ‘I’m so sick of this pain.’ ‘Stop being so pathetic and just get on with it.’
These thoughts add apprehension, pressure and physical tension to an already difficult experience.
Following my own experience with persistent back pain, I became so tense that at times I felt almost contorted. I was caught up in catastrophic thinking, but I had very little awareness of it — I simply believed what I was thinking. It was only through my later training that I began to understand just how much anticipation, emotion and muscle activity influence one another. I wish I’d known then what I know now.
Tension isn’t always obvious. It might be a slight tightening before bending, a held breath, or shoulders that have crept upwards without us noticing.
And then there’s our attention. Are we constantly checking our symptoms? Are we so focused on what might hurt that we’ve lost sight of what we actually want to be doing?
Taking ourselves off autopilot
Awareness is where the door begins to open — not by constantly monitoring Awareness is where the door begins to open — not by constantly monitoring symptoms, but by becoming curious about how we respond to our experience.
Rather than looking at pain as an isolated sensation, we can begin exploring the wider picture:
- How does the sensation actually behave? Does it shift, fluctuate, or turn up with stress or anticipation rather than physical effort?
- What thoughts are accompanying it? Are we catastrophising or leaping ahead to what this means for next week or next year?
- What meaning or history have we attached to this sensation?
- What else might be influencing our nervous system? Stress, relationships, difficult emotions, or perhaps longstanding habits of putting ourselves under pressure or holding back what we feel?
There is a big difference between experiencing a sensation and the story we add to it, just as there is a big difference between curious observation and watching our body for danger.
A thought like ‘This is going to hurt’ feels completely convincing, but it’s a prediction, not a fact. When we recognise these automated responses, we gain the space to pause, question what is helpful, and take ourselves off autopilot.
Our capacity to change
We humans have an extraordinary capacity to learn and adapt throughout our lives through neuroplasticity.
Part of the work I do is helping people become aware of these automatic patterns and the things that shape them. Through neuroplasticity, the nervous system begins to respond in more helpful ways and update its unnecessary protective responses.
In the Boulder Back Pain Study, published in JAMA Psychiatry in 2021, 66% of participants receiving Pain Reprocessing Therapy were pain-free or nearly pain-free after treatment, compared with 20% receiving placebo treatment. The results offer encouraging evidence that learned pain-related patterns can change, even when pain has persisted for years.
I like to view this work as two scientists coming together in a lab. You bring your lived experience, and together we explore your history, environment, and response patterns. From there, we experiment with skills to build new ways of responding — whether that involves making space for uncomfortable sensations, releasing unnecessary tension, or gradually testing what your body can do in everyday life.
If I had one word to sum up what we’re aiming for, it would be flexibility — in our bodies, our thinking, and our nervous systems.
It is about taking back control, rebuilding trust in our bodies, and finding our way back to the lives we want to live.
Reading about these patterns is one thing; learning how to apply them to your own nervous system is another. In my sessions, we do not focus on fixing a ‘broken’ structure; we work with the living system of your brain and body. Together, we gently untangle automatic threat loops, build a steady sense of physical safety, and take your nervous system off autopilot so you can confidently return to the activities you love.
See how we can work together →
Research and further reading
Hasenbring, M. I., & Verbunt, J. A. (2010). Fear-avoidance and endurance-related responses to pain: New models of behavior and their consequences for clinical practice. The Clinical Journal of Pain, 26(9), 747–753.
https://pubmed.ncbi.nlm.nih.gov/20664333/
International Association for the Study of Pain (2020). IASP announces revised definition of pain.
https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/
Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., … & Wager, T. D. (2021). Effect of pain reprocessing therapy on chronic back pain: a randomised clinical trial. JAMA Psychiatry, 78(12), 1320-1328. https://doi.org/10.1001/jamapsychiatry.2021.2669