Physiotherapy and Chronic Pain (including Low Back Pain)
Updated: Nov 19, 2021
This blog is for patients, clients and physiotherapy professionals on how to manage any long term condition such as low back pain and chronic musculoskeletal injuries with current evidence on pain management.
What is pain?
Pain is the body’s protection mechanism to prevent injury. Pain does not mean damage is being caused. It is actually a protective mechanism that buffers tissues in the body from injury.
This buffer is constantly changing depending on a wide range of factors such as previous injury, tissue structure, body’s state of readiness (excitability from fight or flight systems, stress levels and sleep to name a few) and inputs from the brain to modify the pain level. These can be conscious and unconscious.
Pain is affected by three main influences:
Detection of “pain signals” from the body area
History and memory of pain in that area
The brains anticipation of pain.
You do not have to have all of the above and any combination could lead to all types of pain.
Each weighting of the above influences depends on the amount of time you have been in pain, severity and nature of pain, effect of the pain on your life and other factors e.g. stress, anxiety, depression, less rest or diet.
For example, if pain stops you working this is likely to be more severe because it is more important to your life and therefore your brain, to do something about.
This is well known in the medical professions and is often referred to as the biopychosocial model.
So what is chronic pain?
Chronic pain is pain that has lasted over 3 months, but sometimes medical professions wait until 6 months to be more sure. In this time, the body has usually had sufficient time to heal from the initial injury whether it be trauma from a fracture or soft tissue injury e.g. muscle tear, ligament sprain or tendon injuries.
Chronic pain often is a factor of not just tissues, but your brain’s interpretation of pain based on history, anticipation and memories of pain as well.
These interpretations are not always correct and the body can become oversensitive to areas that were once injured that have now healed but are still truly painful.
To understand this it helps to have an idea of how pain is generated by the body.
Detection of “pain signals”:
“Pain signals” travel from the tissues all over the body to the spinal cord and brain where they are adjusted depending on the previous history and anticipation of “threat”.
For example, if you were about to be run over, your brain may choose to ignore your big toe pain or even more serious injury because it is not the most important at the current moment.
It could dampen the signals from that area and ignore it until you were safe.
This happens on a daily basis, but to a lesser extent.
Alternatively, it could increase the signals from the big toe because you are a dancer and could lose your job if unable to dance.
So, the central nervous system (brain and spinal cord) is constantly adjusting how important signals are without you knowing.
History and memory of pain:
Your history and memory of pain affects pain levels because of the body learns to adapt.
For example, if you have had a good experience such as excellent exam results, your body wants to repeat this and likewise avoid pain.
This is a natural response and one almost everyone will do automatically.
Furthermore, the body reacts stronger to negative outcomes like pain, fear and strong emotions. This is thought to be due to needing to avoid “near misses”, fear and pain to survive in nature. These form stronger and more powerful links in the brain which affect your thinking and anticipation of pain amongst many, many other things.
Anticipation of pain:
Detection of signals from the body is interpreted by the brain and this is combined to history and memory of pain to anticipate how much pain you will experience, before the movement has happened.
This is often a bit like a polar bear stepping tentatively onto ice as you expect pain:
This is probably extendable to other feelings and emotions as well, so can be linked to other similar situations in life such as fear and anxiety.
As with history and memory of pain, the body remembers strong emotions and painful events more than daily activities as above.
But, it also sends a signal down to the body to change the amount of pain you experience depending on above.
So that means:
If you really believe that a movement is pain free, enjoyable and causes happiness then it will be less painful:
So, what to do?
Reduce any aggravating activities and more painful movements.
Do not stop all movements and rest up. However, reduce the severe pain that doesn't quickly ease where possible. You could also take pain relief if directed to do so by your doctor.
Note: Movement is still key to rehabilitation as the body wants to move and pain free movements will aid recovery and sensitivity of pain.
Decrease fear and anxiety of pain.
This is harder said than done but from reading this, you can hopefully see that pain does not always equal injury or damage.
Note: Believing you will get better and be pain free with your movements will start to change your mind, even subconsciously.
This will in turn desensitise your brain to the chronic pain and reduce anticipation of pain.
This will mean you can move more freely and further decrease pain.
Visualise and “feel” pain free movements before doing them.
The eyes have the biggest input into the brain (70% of sensory input and 40% of all processing) so visualising pain free movements can reduce the level of pain.
Note: The stronger the visualisation is and the more real, the more effective.
Gradually increase your activities which are pain free by 10% a week.
This should mean you don't step backwards by doing too much, too quickly.
Here at our physiotherapy clinic in Watford, we use this approach where appropriate to enable you to return to function as much as possible.
Please call us or book online via our links above.
I hope you enjoyed reading!
Daniel Leers (mCSP, HCPC, BSc Hons, MChem)
This post was primarily adapted for use by patients and clinicians from Lorimer Moseley's Pain Management course in London, 18-19th May 2019 (citation below):
Dysvik, E., Lindstrøm, T., Eikeland, O., & Natvig, G. (2004). Health-related quality of life and pain beliefs among people suffering from chronic pain. Pain Management Nursing, 5(2), 66-74. doi: 10.1016/j.pmn.2003.11.003
Engel, G. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129-136. doi: 10.1126/science.847460
Engel, G. (1980). The clinical application of the biopsychosocial model. American Journal Of Psychiatry, 137(5), 535-544. doi: 10.1176/ajp.137.5.535
Kirizian, A. (2019). The Eye and Vision. Retrieved 22 July 2019, from https://antranik.org/the-eye-and-vision/
Moseley, L. (2019). Lorimer Moseley in London. In Lorimer Moseley in London. London: NOI Group.
NHS Scotland. (2006). Management of Chronic Pain in Adults. Edinburgh: NHS Scotland.
Physioedge. (2012). Lateral Hip Pain [Podcast]. Retrieved 1 July 2019, from
Treede, R., Rief, W., Barke, A., Aziz, Q., Bennett, M., & Benoliel, R. et al. (2015). A classification of chronic pain for ICD-11. PAIN, 156(6), 1003-1007. doi: 10.1097/j.pain.0000000000000160
Watson, T. (2019). Soft Tissue Repair and Healing Review. Retrieved 22 July 2019, from http://www.electrotherapy.org/modality/soft-tissue-repair-and-healing-review?highlight=tissue%20healing