Your pain rarely lives only in your back.
It lives in your nervous system.
Why your disc is rarely the only cause. And why lasting recovery may happen in tissue, nervous system, breath and your own story at the same time.
For years, I was one of you. I could not get out of bed in the morning without first stretching for half an hour. The suspicion was ankylosing spondylitis. My back was stiff. My nights were short.
What surprised me most came later. My back pain became quieter when I started stepping into ice cold water every morning. At first this makes no sense, because cold tightens tissue immediately. I wrote a book about it, because this apparent contradiction led me into a kind of pain medicine that does not look only at the disc. It looks at posture. At the nervous system. At the story behind the pain.
Back then, no one asked what my nervous system was doing. No one asked why my back was so tense in the first place. No one asked whether my posture could even carry me. No one asked what was happening emotionally in my life. Only when I stopped treating only the tissue and started working on posture, nervous system, relationships and unprocessed inner themes at the same time, did I become lastingly pain free. This article is the map I would have needed back then.
You went for an MRI. They found something. But was that really the pain?
You know that moment. The doctor shows you the image. "See, here, a protrusion. There, a bulging disc. Disc degeneration L4 L5." You nod. Something inside you tightens. Finally an explanation. And at the same time, something heavy: so I am broken.
Before you accept that feeling, let us look at the data for a moment.
A systematic review looked at disc findings in pain free people. Among 20 year olds, 37 percent had disc degeneration. Among 80 year olds, 96 percent. Disc bulges were found in 30 percent of 20 year olds and 84 percent of 80 year olds. These people had no pain. This means: disc findings on an MRI are, in large part, simply tissue ageing. They are not necessarily the driver of your pain.
Brinjikji W et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR. 2015;36(4):811 to 816. DOI: 10.3174/ajnr.A4173
If a finding can exist without causing pain, then that finding cannot be the only reason for the pain. That is a logical sentence. And yet our healthcare system often does not act in line with it. We operate disc herniations that may not be the actual problem. We give injections. We medicate. And the pain stays.
A prospective cohort study compared disc surgery with conservative therapy for lumbar disc herniation. After six weeks, surgical patients had less back pain. After one and two years, that difference had disappeared. Faster is not better when it comes to chronic pain.
Gugliotta M et al. Surgical versus conservative treatment for lumbar disc herniation. BMJ Open. 2016;6(12):e012938. DOI: 10.1136/bmjopen-2016-012938
A finding is a description of your tissue. It is not a complete explanation of your pain. Treatment may include the tissue, but it should not end there.
And now you know why.
Does that mean your posture is irrelevant? On the contrary.
I get this question every time. If the disc is not the main suspect, is mechanics then irrelevant? Please do not think that. The mechanical layer matters, and it matters a lot. It is just something different from what most people believe.
If you sit eight hours in front of a screen, your head falls forward, your shoulders tilt toward your chest, and your lower back forms a hollow you no longer feel consciously, something real happens. Deep stabilisers like the multifidus go quiet. Their fibres can become thinner over time and partly be replaced by fatty tissue. This is measurable on MRI and well documented in chronic back pain populations. Fascia can stick. The diaphragm sits too high and breathes too short. Your pelvis tilts. This pattern is called postural deconditioning, and it can fuel an already irritated pain nervous system.
A meta-analysis of 15 studies found that adults with neck pain showed a significantly more forward head position compared to pain free people. Forward head posture correlated with pain intensity and disability. Mechanics is not a myth. It is a measurable co-factor.
Mahmoud NF et al. The Relationship Between Forward Head Posture and Neck Pain. Curr Rev Musculoskelet Med. 2019;12(4):562 to 577. DOI: 10.1007/s12178-019-09594-y
A randomised trial in 66 older adults with chronic neck pain compared targeted postural correction (using mirror image exercises and a cervical orthotic) with classic physiotherapy. After six weeks, both groups had improved similarly. Three months later, only the postural correction group had maintained the gains. The classic physio group had regressed. Symptom gymnastics may help short term. Structural work tends to hold.
Suwaidi A et al. A Comparison of Two Forward Head Posture Corrective Approaches in Elderly with Chronic Non-Specific Neck Pain. J Clin Med. 2023;12(2):542. DOI: 10.3390/jcm12020542
Among office workers, the one year prevalence of neck pain was 45.5 percent. Risk factors included long sitting in a forward bent posture, mental tiredness at the end of the workday, and understaffing. Mechanics and psychosocial load interact. They cannot be separated.
Cagnie B et al. Individual and work related risk factors for neck pain among office workers. Eur Spine J. 2007;16(5):679 to 686. DOI: 10.1007/s00586-006-0269-7
The problem with classic therapies for back and neck pain is not that they do nothing. The problem is that most of them treat the pain, not the posture that keeps producing it. You get exercises against pain. Mobilisations. Trigger point work. Heat. You feel better short term. Four weeks later you are back, because your architecture is still not carrying you.
From exactly this point, I developed my own posture and statics programme that I work through with my patients in practice. It is not about isolated exercises. It is about the architecture of your body in everyday life. Where does your pelvis sit when you sit? Where does your head rest? Where does your breath go? How do we activate the deep stabilisers that no one ever showed you?
Important: this programme does not start in acute pain, but once the nervous system has become quieter. Working on statics in an active pain spasm often increases the pain. First calm, then alignment.
Your back is not a stack of separate vertebrae. It is a living, guided structure. When the architecture lines up, the nervous system has fewer reasons to sound the alarm.
And now you know why "exercises against pain" alone tend to be short lived.
Your nervous system decides whether it hurts
Here comes the part many patients hear for the first time in their life: pain is not generated in the back. Pain is generated in the brain. The back sends signals, the brain decides what counts as threat and what does not.
For acute pain this system is useful. You step on a sharp stone, the system shouts, you lift your foot. That is life protection. But in chronic pain, this system can take on a life of its own. It shouts even when the stone is long gone. We call that central sensitisation.
- An injury or overload in the tissue sends signals to the spinal cord and brain.
- The nervous system learns to give this region heightened attention. The signal amplifiers in the spinal cord get turned up.
- Brain circuits (anterior insula, anterior cingulate cortex, medial prefrontal cortex) become overactive. They link pain with fear, meaning, and danger.
- Even when the tissue has long healed, the nervous system can keep the pain pattern going. Pain can become memory.
An imaging study compared people with chronic low back pain to healthy controls. The pain patients showed lasting changes in activity within the so called pain matrix and the default mode network. Changes in the precuneus mediated the relationship between pain threshold and pain intensity. In other words: the brain had adapted to being in pain.
Fan N et al. Neural correlates of central pain sensitization in chronic low back pain: a resting-state fMRI study. Neuroradiology. 2023;65(9):1389 to 1402. DOI: 10.1007/s00234-023-03191-0
Once you understand this mechanism, it changes everything. You are not hypochondriac. You are not dramatic. Your back hurts because your nervous system is stuck in an alarm it cannot switch off on its own.
This is also why the fear of movement can become a pain driver in itself. People who stop moving because they are afraid of breaking something often end up with weaker deep stabilisers, more fascial stickiness, less proprioceptive input to the nervous system. The system gets even more anxious. The model is called fear-avoidance, and it has been an established part of pain research for over twenty years.
The fear-avoidance model shows: not pain alone, but the fear of pain, catastrophising and avoidance may decide whether an acute back pain becomes chronic. Studies in patients with chronic low back pain found that catastrophising and movement fear could explain around 35 percent of the variability in disability.
Vlaeyen JWS, Linton SJ. Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art. Pain. 2000;85(3):317 to 332. DOI: 10.1016/S0304-3959(99)00242-0
Your nervous system is not your enemy. It is an alarm system that has overshot. It is allowed to learn again that your back is safe. That, exactly, is treatment.
And now you know why pure exercise is often not enough.
The study that may have changed everything
In 2021, JAMA Psychiatry published a study that quietly shifted the field of pain medicine. It is called pain reprocessing therapy. Translated: relearning pain.
151 adults with chronic back pain of, on average, ten years duration were randomised: one group received pain reprocessing therapy (PRT), one received an open label placebo, one received usual care. PRT consists of a medical orientation plus eight psychological sessions over four weeks. At its core, the patient learns to reframe pain not as tissue damage, but as harmless brain activity.
The result: 66 percent of the PRT group were pain free or nearly pain free at the end, compared with 20 percent in the placebo group and 10 percent in usual care. fMRI scans showed reduced activity in the anterior insula and anterior cingulate cortex in PRT patients. The effect held at the 5 year follow up.
Ashar YK et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain. JAMA Psychiatry. 2022;79(1):13 to 23. DOI: 10.1001/jamapsychiatry.2021.2669
66 percent. That is not a small improvement. It is more than most surgeries deliver. And it happens without scalpel, without injection, without pill. It happens through a neurobiological learning process.
A second research group around Donnino, Ashar and Schubiner studied a related approach called psychophysiologic symptom relief therapy. Same logic. Similar result.
Three arms: psychophysiologic symptom relief therapy, MBSR (mindfulness-based stress reduction), usual care. 63.6 percent of the PSRT group were pain free after 26 weeks, compared with 25 percent in MBSR and 16.7 percent in usual care. PSRT focuses on educating patients that emotional processes, rather than tissue damage, may sustain the pain.
Donnino MW et al. Psychophysiologic symptom relief therapy for chronic back pain: a pilot randomized controlled trial. Pain Reports. 2021;6(3):e959. DOI: 10.1097/PR9.0000000000000959
A large randomised study compared mindfulness-based stress reduction, cognitive behavioural therapy, and usual care in 342 patients with chronic back pain. Both MBSR and CBT led to clinically meaningful functional improvement in around 60 percent of cases, compared with 44 percent in usual care. The effect held up to 52 weeks.
Cherkin DC et al. Effect of MBSR vs CBT or Usual Care on Back Pain and Functional Limitations. JAMA. 2016;315(12):1240 to 1249. DOI: 10.1001/jama.2016.2323
Pain that has not gone away for years can be a memory of your nervous system. Memories can be treated.
Trauma may sit in the back
Here it gets personal. When I ask my patients in practice what was going on at the time their back first started to hurt, I rarely hear "nothing". I hear separations. Losses. Bullying. A difficult birth. A mother's diagnosis. Taking over a company. A relationship in which something was kept silent.
This is, with high probability, not coincidence. From the perspective of clinical psychoneuroimmunology and pain physiology, unprocessed emotions and trauma can shift fascial tone, breathing patterns, postural muscle tone and the autonomic nervous system over time. They can support silent inflammation. And they can lower the threshold at which the brain interprets a signal as pain. This is physiologically plausible and supported by mechanism studies. The full causal chain in humans has not yet been demonstrated within a single, large randomised study, but rather in many converging mosaic pieces.
A systematic review found: even one Adverse Childhood Experience increases the risk of reporting chronic pain in adulthood by 29 percent. With four or more ACEs, the risk is almost twice as high (aOR 1.95). Childhood physical abuse increases the risk of chronic pain by 50 percent and pain-related disability by 46 percent.
Bussières AE et al. Adverse childhood experience is associated with an increased risk of reporting chronic pain in adulthood: a systematic review and meta-analysis. Eur J Psychotraumatol. 2023;14(2):2284025. DOI: 10.1080/20008066.2023.2284025
A trial in older veterans with chronic musculoskeletal pain compared emotional awareness and expression therapy (EAET) with classic CBT. 41.7 percent of EAET patients achieved more than 30 percent pain reduction, one third more than 50 percent, and 12.5 percent more than 70 percent. In the CBT group, only one single patient reached this threshold. EAET works deliberately with unspoken emotions, conflicts, and unspoken truths.
Yarns BC et al. Emotional Awareness and Expression Therapy Achieves Greater Pain Reduction than CBT in Older Adults. Pain Medicine. 2020;21(11):2811 to 2822. DOI: 10.1093/pm/pnaa145
My back was stiff for years. I thought I had a skeletal problem. Today I know that my lower back was loudest when I avoided conflict in relationships. When I did not allow myself to show aggression. When my sexuality touched topics I had not looked at.
I did not believe this back then. I was a clinician. I wanted a clean, mechanical reason. Only when I started addressing aggression, sexuality, and relational patterns in therapy did my back become lastingly quiet. I cannot claim this is the same for you. I can only say: I know this pattern very well.
If your pain is telling stories about you, then you do not only need movement. You need the right to tell those stories. Psychotherapy is not an add-on. It can be primary treatment.
And now you know why pure physiotherapy is often not enough.
HRV: the stress you can actually measure
Stress is too big a word. It means everything and nothing. We say "I am stressed" and we mix together time pressure, poor sleep, relationship worries, unspoken conflicts, sensory overload.
What we can measure objectively is whether your autonomic nervous system is currently in protection mode or in recovery. We do that with heart rate variability, or HRV. From an ECG recording you can read how flexibly your heart responds to each breath. High HRV reflects an alert, calm vagus nerve. Low HRV means your body is on continuous alarm.
A meta-analysis confirmed: in chronic pain, high-frequency HRV is moderately to strongly reduced. This means the brake pedal of the autonomic nervous system, the parasympathetic branch, is working at lower capacity. The body's own pain inhibition system is dampened.
Tracy LM et al. Meta-analytic evidence for decreased heart rate variability in chronic pain. PAIN. 2016;157(1):7 to 29. DOI: 10.1097/j.pain.0000000000000360
A systematic review showed that structured exercise over four to 24 weeks may improve HRV in chronic musculoskeletal pain, especially the vagally mediated measures at rest. Exercise is therefore not only "muscle building". It is nervous system training.
Meus T et al. Exercise and Heart Rate Variability in Chronic Musculoskeletal Pain: A Systematic Review. Sports Med Open. 2025;11:6. DOI: 10.1186/s40798-024-00789-3
In my practice on Skalitzer Strasse in Berlin, that is exactly what we measure. A 24 hour ECG with HRV analysis shows you in black and white where your nervous system stands today. This is not an esoteric gut feeling. It is biology. And it can be worked with.
If someone tells you that you are stressed, and you nod back annoyed, you are talking past each other. If your HRV shows your vagus nerve is quiet, you have a task. And a lever.
Toxins that may shift your tension baseline
There are patients whose shoulder and neck tension does not budge, even though everything else fits. They sleep, they move, they have done therapy. Still they stay tight. Here it is worth looking at a layer that is rarely discussed: toxic load. Important upfront: this is not a main mechanism for most patients. It is a relevant side path for a subset.
Mycotoxins, mould toxins, can be absorbed through skin, airways, and gut. They activate mast cells and pro-inflammatory cytokines. They can affect the central and peripheral nervous system. Patients can report musculoskeletal complaints, neurocognitive symptoms, exhaustion. In one study of ME/CFS patients with documented mould exposure, 92.4 percent had detectable mycotoxins in urine.
Ratnaseelan AM et al. Effects of Mycotoxins on Neuropsychiatric Symptoms and Immune Processes. Clinical Therapeutics. 2018;40(6):903 to 917. DOI: 10.1016/j.clinthera.2018.05.004
Heavy metals such as mercury, lead, cadmium and arsenic generate oxidative stress. They can displace essential trace elements like zinc and selenium. They may block enzymes and damage mitochondria. In a study of metal industry workers, measurable damage to small nerve fibres was found, the fibres that transmit temperature and pain.
Jomová K et al. Heavy metals: toxicity and human health effects. Archives of Toxicology. 2024;98(1):153 to 209. DOI: 10.1007/s00204-023-03562-9. Also Koszewicz M et al. The impact of chronic co-exposure to different heavy metals on small fibers. J Occup Med Toxicol. 2021;16:12. DOI: 10.1186/s12995-021-00302-6
What does this mean practically? If you live in an apartment with damp walls, if you have worked for years in a polluted environment, if your symptoms are diffuse, multi-system and treatment-resistant, then toxic load should be measured along with everything else. Otherwise we treat the tip of the iceberg, not the iceberg.
Cold, breath and a possible reset of the nervous system
Here it gets unusual. I will tell you what made the difference for me: ice baths. I hear you thinking: "but cold tightens, doesn't it?". Exactly, in the moment of application. But what happens afterwards may include a strong recovery of the vagus nerve.
A systematic review of the Wim Hof method (breathwork, cold exposure, mindset) found signals of reduced inflammation: increased adrenaline, higher interleukin-10 and lower pro-inflammatory cytokines in healthy and non-healthy participants. The evidence base is small, the effects are plausible, and direct transfer to chronic back pain is not yet proven.
Almahayni O et al. Does the Wim Hof Method have a beneficial impact on physiological and psychological outcomes? PLOS ONE. 2023;18(3):e0286933. DOI: 10.1371/journal.pone.0286933
I was so stiff that I could not get out of bed in the morning without 30 minutes of stretching. I started stepping into cold water for a few minutes every morning. At first it was just an idea born of desperation. After weeks I noticed that my sleep got deeper, my morning heart rate calmer, my back less afraid.
I do not claim that cold healed my back. I claim that it could reset my nervous system, so that everything else I was doing (therapy, posture work, relational work) could finally land. I wrote a book about this, because exactly this seeming paradox kept occupying me.
Important: cold exposure is a tool, not a miracle. With heart conditions, severe blood pressure dysregulation, and during pregnancy, it is not suitable for everyone. Please speak with your physician first.
What a holistic approach may look like
I do not treat patients with one method. I work with a picture of you that sees several layers at once. Not all of these layers are equally relevant for every person. We decide together where to pull the lever first. This is the underlying logic of clinical psychoneuroimmunology and functional medicine: five pillars that hold each other, instead of one single treatment that is supposed to do everything alone.
1. Mechanically realign, posture instead of symptom gymnastics
I have developed my own posture and statics programme that brings people, step by step, into a more carrying alignment. It is not about exercises against the current pain. It is about changing the architecture of your body so that the same loading patterns no longer produce the same pain. This includes pelvis, deep core stabilisers, breathing, the shoulder-neck axis, and how you handle sitting in everyday life.
2. Regulate the nervous system, trauma and psychotherapy, stress management
If your nervous system is stuck in chronic protection, every mechanical intervention will only go so far. I combine PNI-oriented psychotherapy, trauma-sensitive methods, nonviolent communication, coherent breathing, and HRV diagnostics. We make it measurable whether your vagus is working stably. And we work specifically on what is preventing it.
3. Plant-based and anthroposophic support
In certain phases, plant-based and anthroposophic remedies may meaningfully complement the work. They are never a replacement for the other pillars, but they may support pain, sleep, inflammatory tendency, and inner experience. Which remedy fits which constellation, we discuss individually.
4. Relieve the immune system, toxins and silent inflammation
If history and basic markers suggest it, we investigate mould exposure, heavy metals, gut health, and chronic inflammation markers. What keeps the immune system quietly busy in the background may keep the pain system quietly turned on. Relieving this load may give the nervous system more room to recover.
5. Improve metabolism, energy at the cellular level
Mitochondria are the power plants of your muscle, fascia, and nerve cells. If they produce too little ATP, the tissue in the painful region has less reserve against load, stress, and repair work. Micronutrients such as magnesium, B vitamins, iron, vitamin D, and a targeted metabolic rebuild may improve energy delivery in the affected area.
These five pillars are not a rigid scheme. They are a map on which we decide together in what order we move. For one patient, statics is the lever. For another, it is trauma. For the next, it is toxins. For many, it is the combination that may make the difference.
Three levers you can start with today
First lever. Learn not to believe your pain. This does not mean "ignore it". It means "reframe it". When pain spikes, tell yourself: this is my nervous system speaking up. My tissue is not in danger. This single cognitive move can train your brain to recalibrate. It is the heart of what pain reprocessing therapy teaches.
Second lever. Breathe coherently for five minutes a day. Four seconds in, six seconds out, through the nose if possible. This is the only conscious activity that directly addresses your vagus nerve. It costs nothing and the evidence base shows consistent effects on HRV.
Third lever. Write an honest list with the title "What am I currently not saying". Do not share. Do not show. Just for you. Read it three days later. If you feel tears, anger or relief, you have a clue where your nervous system is currently carrying weight.
Being pain free is not a luxury. It is the precondition for being yourself again, instead of constantly playing gatekeeper inside your own body. This freedom is reachable. But it needs a plan that sees more than just your disc.
If you do not only want to read but to start now, you will find the option to book an appointment below this article. We measure, we listen, we build a plan with you that treats your nervous system, your story, and your body as one unit.
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