u/ThysicalPherapist

I’ve spent years treating people with chronic back pain. One of the biggest problems I see is that people are forced into extremes. Either “Your spine is broken and degenerating.” OR “Nothing is wrong with you, it’s all stress.”

Most people with chronic back pain end up stuck somewhere in the middle of those two narratives with no real framework for understanding what’s happening to them. So I wanted to share a few things that I think are important. These are perspectives that genuinely seem to help people make better decisions and calm down some of the confusion. They are not absolute truths.

Firstly… Pain is real. Very real. But pain is also more complicated than tissue damage alone. That’s not me minimizing anyone’s symptoms. If anything, it’s the opposite. Pain is produced by the nervous system after it weighs a massive amount of information. Mechanical stress, inflammation, previous injury history, sleep, stress, fear, conditioning, physical capacity, threat perception, movement variability, general health, expectations, etc.

That’s why two people can have nearly identical MRIs and completely different pain experiences. And yes imaging DOES matter sometimes. There are absolutely cases where structural pathology is clinically important. But we also know from large studies that many “abnormalities” on MRI are incredibly common in people without pain at all.
Disc bulges, degeneration, annular tears, facet changes… these things become more common with age, including in asymptomatic people. That does NOT mean your pain is fake. It means the relationship between imaging and pain is not always linear.

One of the biggest traps I see people fall into is becoming hyper-fixated on finding the ONE damaged structure responsible for every symptom they feel.
Sometimes there is a clear driver. A lot of times, especially in chronic cases, it’s more complicated than that. The World Health Organization’s recent chronic low back pain guidelines actually emphasize a “biopsychosocial” approach. Meaning that physical, psychological, and social factors all interact together in chronic pain states. They recommend education, exercise, staying active, self-management strategies, and individualized care rather than purely passive treatment models.

And before anybody gets angry at the word “psychological”… that does NOT mean your pain is imaginary. Stress, fear, hypervigilance, poor sleep, catastrophizing, loss of confidence, and constantly guarding movement can absolutely amplify a very real physical pain experience. That’s neuroscience.

Another thing. A lot of people are unintentionally trapped in cycles of fear and overprotection. They stop bending, walking, exercising, loading their bodies, trusting themselves. And over time, the body often becomes less tolerant, less conditioned, more guarded, and more sensitive. This is why graded exposure and individualized movement matter so much. This does not mean we should “just push through pain.” But it also doesn’t mean “never move again.” Finding tolerable entry points, no matter how small, and rebuilding confidence gradually is the path out of it.

Research consistently supports exercise and activity for chronic low back pain, but interestingly, no single magical exercise system appears overwhelmingly superior for everybody. The best program is usually the one a person can tolerate, understand, progress, and stick with consistently. (jpain.org)

A few things that do seem to help many people…

1. ⁠improving sleep
2. ⁠walking more consistently
3. ⁠reducing all-or-nothing activity cycles
4. ⁠improving general strength/capacity
5. ⁠pacing flare-ups better
6. ⁠reducing fear around movement
7. ⁠getting stronger at movements they’ve been avoiding
8. ⁠understanding pain better
9. ⁠calming down the constant “my spine is crumbling” narrative

And yes… sometimes people DO need injections. Sometimes surgery is appropriate. Sometimes there are real neurological deficits or red flags that absolutely need medical attention. But for a huge percentage of chronic back pain sufferers, the answer is usually not found in endlessly chasing the perfect correction, perfect stretch, perfect posture, perfect MRI finding, or perfect passive treatment.

It’s usually a slower process of understanding, desensitizing, rebuilding, reloading, and regaining trust in your body again.

None of this is meant to invalidate anybody’s experience. Chronic pain can completely take over your life. I’ve seen it firsthand and dealt with severe spine issues and unfortunately over 12 years of chronic back pain myself. I just think people deserve more nuanced conversations than “you’re damaged forever” or “it’s all in your head.” Both of those narratives can become prisons.

I’ve spent years treating people with chronic back pain. One of the biggest problems I see is that people are forced into extremes.

Either “Your spine is broken and degenerating.” OR “Nothing is wrong with you, it’s all stress.”

Most people with chronic back pain end up stuck somewhere in the middle of those two narratives with no real framework for understanding what’s happening to them. So I wanted to share a few things that I think are important. These are perspectives that genuinely seem to help people make better decisions and calm down some of the confusion. They are not absolute truths.

Firstly… Pain is real. Very real. But pain is also more complicated than tissue damage alone. That’s not me minimizing anyone’s symptoms. If anything, it’s the opposite. Pain is produced by the nervous system after it weighs a massive amount of information. Mechanical stress, inflammation, previous injury history, sleep, stress, fear, conditioning, physical capacity, threat perception, movement variability, general health, expectations, etc.

That’s why two people can have nearly identical MRIs and completely different pain experiences. And yes imaging DOES matter sometimes. There are absolutely cases where structural pathology is clinically important. But we also know from large studies that many “abnormalities” on MRI are incredibly common in people without pain at all.
Disc bulges, degeneration, annular tears, facet changes… these things become more common with age, including in asymptomatic people. That does NOT mean your pain is fake. It means the relationship between imaging and pain is not always linear.

One of the biggest traps I see people fall into is becoming hyper-fixated on finding the ONE damaged structure responsible for every symptom they feel.
Sometimes there is a clear driver. A lot of times, especially in chronic cases, it’s more complicated than that. The World Health Organization’s recent chronic low back pain guidelines actually emphasize a “biopsychosocial” approach. Meaning that physical, psychological, and social factors all interact together in chronic pain states. They recommend education, exercise, staying active, self-management strategies, and individualized care rather than purely passive treatment models.

And before anybody gets angry at the word “psychological”… that does NOT mean your pain is imaginary. Stress, fear, hypervigilance, poor sleep, catastrophizing, loss of confidence, and constantly guarding movement can absolutely amplify a very real physical pain experience. That’s neuroscience.

Another thing. A lot of people are unintentionally trapped in cycles of fear and overprotection. They stop bending, walking, exercising, loading their bodies, trusting themselves. And over time, the body often becomes less tolerant, less conditioned, more guarded, and more sensitive. This is why graded exposure and individualized movement matter so much. This does not mean we should “just push through pain.” But it also doesn’t mean “never move again.” Finding tolerable entry points, no matter how small, and rebuilding confidence gradually is the path out of it.

Research consistently supports exercise and activity for chronic low back pain, but interestingly, no single magical exercise system appears overwhelmingly superior for everybody. The best program is usually the one a person can tolerate, understand, progress, and stick with consistently. (jpain.org)

A few things that do seem to help many people…

1. improving sleep
2. walking more consistently
3. reducing all-or-nothing activity cycles
4. improving general strength/capacity
5. pacing flare-ups better
6. reducing fear around movement
7. getting stronger at movements they’ve been avoiding
8. understanding pain better
9. calming down the constant “my spine is crumbling” narrative

And yes… sometimes people DO need injections. Sometimes surgery is appropriate. Sometimes there are real neurological deficits or red flags that absolutely need medical attention. But for a huge percentage of chronic back pain sufferers, the answer is usually not found in endlessly chasing the perfect correction, perfect stretch, perfect posture, perfect MRI finding, or perfect passive treatment.

It’s usually a slower process of understanding, desensitizing, rebuilding, reloading, and regaining trust in your body again.

None of this is meant to invalidate anybody’s experience. Chronic pain can completely take over your life. I’ve seen it firsthand and dealt with severe spine issues and unfortunately over 12 years of chronic back pain myself. I just think people deserve more nuanced conversations than “you’re damaged forever” or “it’s all in your head.” Both of those narratives can become prisons.

What has been bothering me lately is how many people with chronic back pain seem completely mentally trapped by it.. and honestly I understand why because I’ve lived it.

After a while you stop trusting anything. You don’t trust movement. You don’t trust flare-ups. You don’t trust your MRI. You don’t trust providers because everyone says different shit. You don’t trust yourself because every time you think you figured it out, symptoms change again.

I see people online arguing over

1. core weakness
2. instability
3. SI joints
4. mind-body pain
5. posture
6. disc bulges
7. nervous system sensitization
8. walking
9. stretching

And the list goes on and on (and on and on) lol.

And after years of this I honestly think a lot of people become hyperaware of every sensation in their body and start living in “management mode” 24/7.

I dealt with that myself for a long time both before and after surgery. It’s one of the reasons I became a clinician.

I’ve actually been putting together a bunch of thoughts/resources around this whole problem because I’m tired of seeing either

1. fear-based medical explanations
2. or
3. influencer nonsense

I genuinely just want to make something that actually helps people feel less lost. But before I continue building it, I’m curious… What’s the thing about your back pain that messes with your head the most?

EDIT: Lots of responses here and I genuinely appreciate everybody who’s chatting with me. I will reply to everybody as soon as I can! If you prefer to chat privately and not air your info in the comment section, I’m happy to talk privately too.

I dealt with chronic back pain for years (and surgery)

The hardest part for me personally wasn’t the pain. It was not knowing what was safe, what was actually making things worse, and what actually mattered long term.

Most people aren’t lacking exercises. There’s no shortage of resources that are readily available. The biggest problem that I notice is that people are lacking clarity. A lot of those resources fail because it’s like trying to fit a square peg into a circular hole. The solution doesn’t match the problem, and the
problem is hardly understood.

I know what helped me in the past (clarification on my problem, learning to grade exposure, not judging setbacks as failures, using information to guide my recovery, etc.) but I’m curious about other’s experiences…

If someone or something could actually help you understand your pain better…What would you want that to look like? Step-by-step guidance? Explanations in plain English? Help knowing what to do during flare-ups? Or something else?

What’s something about your pain that still doesn’t make sense to you?

When your pain flares up… what do you actually do in that moment? Do you stop everything? Do you push through it? Do you try to ‘fix’ it?

I’m going to be blunt because I don’t think sugarcoating this helps me.

I’ve spent my entire life following (more or less) structured paths. School —> doctorate —> job. I know how to work hard. I know how to get good at something when the rules are clear.

But now I’m trying to build something of my own, and I feel like I have no idea what I’m doing.

I’m a physical therapist working full time. I have a family. I can’t just quit and “go all in” without risking everything, so I’m trying to build something on the side to earn back my freedom and build a business, not just a job.

And that’s where things start falling apart. I’ve created a product I genuinely believe in. It’s not some drop-shipped garbage. I actually care about it and the people it’s for. But when it comes to getting people to see it, understand it, and buy it, I feel completely out of my depth.

Marketing feels like trying to learn 10 different professions at once. Copywriting, Paid ads (Meta, Google), funnel building, content creation, scripting, filming, editing, analytics, positioning etc.

Everyone says “just start.” And I have. But it feels like I’m just guessing.

I haven’t really run ads before. I’ve built landing pages. I’ve consumed courses and books. But if I’m being honest, it feels like I’m just piecing together random tactics without understanding what actually matters.

And the biggest issue is that I don’t trust my own judgment yet.

1. I don’t know what skills actually move the needle early on.
2. What I should ignore vs focus on.
3. Whether I should be learning ads, or content, or sales, or all of it.
4. How to make this more efficient while still working a full-time job.

I fully understand this takes time. I’m not looking for a shortcut. But I am trying to avoid wasting the next 1–2 years spinning my wheels because I’m learning the wrong things in the wrong order.

So for those of you who have actually built something (especially while working another job):

If you were starting over in my position, what would you focus on first?

What actually mattered for you?
What skills did you learn that changed everything?
What did you think mattered that turned out to be a waste of time?
What would you double down on if you had limited time and real financial pressure?

I don’t mind hard work. I just don’t want to be blindly working.

Appreciate any honest input—even if it’s blunt.

I’m a PT (and a former chronic back pain sufferer of ~12 years) and I’ve treated a lot of folks with chronic or recurring back pain, myself included.

And honestly… this is the question I hear more than anything.

“I was good for weeks/months and then it just came back out of nowhere.”

It feels random. It feels like your body betrayed you.

But it’s almost never random.

What I usually see is:

Someone WAS moving better… but didn’t actually understand why. They felt good so they changed something (more load, paying less attention, different routine — all technically good things especially for those with chronic pain). But somewhere along the way their body either lost tolerance to, or was never taught to tolerate those changes…. Then there’s a flare up.

Those “random” flare ups happen generally when folks do too much, too fast after doing too little, for too long. You bend down to put on your sock and “suddenly” you’re out of commission for the next week.

The problem is most people are either:

A) Just following instructions

“Do these exercises”

“Stretch this”

“Strengthen that”

But were never educated about the WHY by the professionals they work with (because many professionals, respectfully, don’t know their asses from their elbows when it comes to back pain).

Or B) Have neglected regular bodily hygiene like reaching basic activity guidelines.

So when something changes (a twist, a weird bend, etc.) their body treats that movement variability as novel. The body spasms or increases pain sensitivity as the nervous system’s protective mechanism. It’s basically telling you to not do that again because “we don’t know how to handle that”. This is where graded exposure work really shines.

Most folks don’t have a way to logically adjust and this stuff can feel quite scary. So they just guess.

That’s the part I think is missing from most rehab. Just a better understanding of what your body is actually responding to, so the mystique is removed from the equation and people can follow a logical progression.

Curious if this matches what people here experience or if you feel like your pain really is random.