Chronic Back Pain: Why It Lingers and What Helps

What is chronic back pain?

Back pain is called chronic when it has lasted for three months or more. It may be there all the time, or come and go with flare-ups. Most people with chronic back pain have no single damaged structure that explains it, which can be frustrating, but it also means the outlook is often better than people fear.

Why does back pain last?

Research over the past two decades has shown that long-lasting back pain is shaped by many things at once:

• A sensitised nervous system. After a while, the nervous system can become more protective, producing pain with less trigger. See central sensitisation.
• Protective movement. Bracing, guarding and avoiding bending often make sense early on, but over time they can increase stiffness and pain.
• Beliefs and fear. Believing that pain means damage, or that the back is fragile, is linked with slower recovery.
• Sleep, stress and mood. Poor sleep and stress both turn up pain. Pain then disturbs sleep, and the cycle continues.
• Lifestyle. Low activity, smoking and carrying extra weight are linked with ongoing pain.

Scans often show disc bulges or wear, but these changes are common in people without any pain and don’t usually explain why pain persists.

What helps chronic back pain?

• Exercise. A 2021 Cochrane review found exercise probably reduces pain and improves function in chronic back pain. The type matters less than doing it regularly. See exercises for lower back pain.
• Cognitive functional therapy (CFT). CFT combines movement retraining with exploring the beliefs, fears and habits linked to pain. In the RESTORE trial of 492 Australians with chronic, disabling back pain, published in The Lancet in 2023, CFT produced large and lasting improvements in disability compared with usual care.
• Psychological treatments. A 2022 analysis in the BMJ found that cognitive behavioural therapy and pain education programmes improved pain in chronic back pain, especially when combined with physical treatment.
• Pain education. Learning how pain works can reduce fear and make it easier to move.
• Sleep and stress. Treating poor sleep and stress can lower pain.

What about medicines and procedures?

Medicines play a limited role in chronic back pain, and some carry significant risks with long-term use. Injections and surgery help some people with specific problems, but they aren’t the answer for most chronic back pain. Your GP can talk through whether any of these suits your situation, and refer you if a procedure is worth considering.

How a GP can help

A GP can check for anything that needs further tests, review your current treatment and put together a plan that covers movement, sleep, stress and pain. That might include referrals to a physiotherapist, exercise physiologist or psychologist. People with chronic conditions may be eligible for some Medicare-subsidised allied health sessions.

References

1. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018;391(10137):2356-2367.
2. Hayden JA, Ellis J, Ogilvie R, et al. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev. 2021;9(9):CD009790.
3. Kent P, Haines T, O'Sullivan P, et al. Cognitive functional therapy with or without movement sensor biofeedback versus usual care for chronic, disabling low back pain (RESTORE): a randomised, controlled, three-arm, parallel group, phase 3, clinical trial. Lancet. 2023;401(10391):1866-1877.
4. Ho EK, Chen L, Simic M, et al. Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis. BMJ. 2022;376:e067718.
5. Louw A, Zimney K, Puentedura EJ, et al. The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiother Theory Pract. 2016;32(5):332-55.
6. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018;391(10137):2368-2383.