Your pain rarely lives only in your back.
It lives in your nervous system.
Why your disc is rarely the only cause. And why treatment that can move something usually works on several layers at once: tissue, nervous system, breath and your own story.
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. That suspicion was assessed by a rheumatologist in my case. My story does not replace that assessment for you.
What surprised me most came later. My back pain became quieter when I started stepping into ice cold water every morning. Whether the cold was the reason, I cannot prove. I can only describe the sequence in time. At first it 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.
Those questions did not come up back then. What my nervous system was doing. Why my back was so tense in the first place. Whether my posture could even carry me. What was happening emotionally in my life. I do not think that was down to individual colleagues. It was down to the time an appointment allows, and to the fact that we all learned with the picture we learned with. I only understood later which questions I had been missing. 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 my back become noticeably quieter over the years. That is my story, not a treatment outcome I can promise you. This article is the map I would have needed back then.
This article is about chronic, non-specific back and neck pain. That means pain where a medical examination has already ruled out dangerous causes. That is the precondition for everything written here.
Please get medical assessment promptly if any of these apply to you: numbness in the saddle region, new bladder or bowel disturbance, increasing weakness or paralysis in a leg or arm, fever together with back pain, unintended weight loss, pain after a fall or accident, a newly appeared severe back pain in older age or with known osteoporosis even without a relevant fall, severe pain at rest or at night, a history of cancer, treatment with corticosteroids or immunosuppressants, or neck pain that starts suddenly and comes with visual disturbance, speech disturbance or dizziness.
Please also get a rheumatology assessment if your back pain started before the age of 45, if you are stiff for longer than 30 minutes in the morning, if the pain wakes you in the second half of the night, and if it improves with movement and worsens with rest. That can point to an inflammatory spinal condition, for example axial spondyloarthritis, formerly called ankylosing spondylitis. There are good treatments for it, and early assessment counts.
With sudden paralysis, sudden bladder or bowel disturbance, chest pain, or a tearing pain between the shoulder blades, call your emergency number immediately (112 in Germany, 999 in the UK, 911 in the US). Not the clinic appointment line.
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. The authors conclude that many of these changes are likely part of normal ageing and unassociated with pain. So a finding on an MRI can be ageing. It can also have something to do with your pain. That can only be decided if the image fits the clinical picture.
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 is not automatically the only reason for the pain. In practice this means: the image alone does not decide, it has to fit the clinical picture. That is exactly what the authors of the review write themselves. Surgery, injections and medication have a firm place where the indication is clear, and for certain findings they are indispensable. So the question is not whether they are needed. The question is whether, for a pain that has stayed for years, every layer has really been looked at.
A prospective cohort study in 370 people compared disc surgery with conservative therapy for lumbar disc herniation. After six weeks, the operated patients improved distinctly faster: 48 percent versus 17 percent reached a halving of their symptoms. After one year the difference in back pain had disappeared, while a small advantage for surgery remained measurable in physical function (minus 3.7 points, 95 percent confidence interval minus 7.4 to minus 0.1). After two years no relevant differences remained. The study was not randomised, so the groups may have differed from the start. What I read from this: where the indication is clear, surgery can be the faster route. Where a pain has stayed for years without such an indication, it is worth looking at the other layers.
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 can become less active. MRI studies in people with chronic back pain describe these muscles as smaller in cross-section and higher in fat content. Whether that is the cause of the pain or its consequence is not settled by such studies. Connective tissue can also lose some of its glide, the diaphragm can sit higher and breathe shorter, the pelvis can tilt. This chain is physiologically plausible, and the individual links are backed by evidence of varying strength. This pattern is called postural deconditioning, and it can fuel an already irritated pain nervous system.
A meta-analysis pooled 15 cross-sectional studies. Adults with neck pain showed a more forward head position than pain free people, and the difference was only just statistically significant. In adults and older adults, head posture was associated with pain intensity and disability. In adolescents, that association was not found. Mechanics is not a myth. It is a measurable association. Because every included study is a snapshot, it cannot tell us whether posture drives the pain or the pain drives the posture.
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 (mirror image exercises plus a cervical orthotic) with a standard stretching and strengthening programme. After six weeks, both groups had improved similarly. Three months later, only the postural correction group was still at the improved level. Important context: the trial is small, follow-up ran only three months, and two of the authors belong to the organisation that promotes the method under test. Independent replication is still missing. I read this as a signal, not as proof.
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
Exercises, mobilisations, manual techniques and heat can work very well, and many physiotherapists have long been working exactly the way I describe here. What I still hear often in my consultations: it got better short term, and a few weeks later the pain was back. One possible explanation is that the work went against the current pain rather than against the pattern that keeps producing it. That is my clinical observation, not a finding from a study.
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 everyday life often leaves out?
Important: this programme does not start in acute pain, but once the nervous system has become quieter. In my experience, working on statics in the middle of an acute flare can increase the pain. This sequence is not proven in studies, it is my clinical experience. 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 a part that short appointments often have no room for. The back sends signals. Whether those signals become pain is decided in the nervous system and in the brain. Signal and pain are not the same thing. That is also the widely held view in pain research today.
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 can learn to give this region heightened attention. The signal amplifiers in the spinal cord can get turned up.
- Brain circuits (anterior insula, anterior cingulate cortex, medial prefrontal cortex) can become overactive. They can link pain more tightly with fear, meaning, and danger.
- Even when the tissue is no longer damaged, the nervous system can keep the pain pattern going. Pain can become memory.
This is an explanatory model. How far it really carries in chronic back pain continues to be debated in the specialist literature.
An imaging study compared 56 people with chronic low back pain to 56 healthy controls. The pain group showed altered resting activity within the so called pain matrix and the default mode network. In the analysis, the link between altered precuneus activity and pain intensity was mediated by the pain threshold. This is a snapshot, not a course over time. It shows that something in the brain changes alongside chronic pain. Whether the brain makes the pain or the pain changes the brain, a study of this design cannot answer.
Fan N et al. Neural correlates of central pain sensitization in chronic low back pain: a resting-state fMRI study. Neuroradiology. 2023;65(12):1767 to 1776. DOI: 10.1007/s00234-023-03237-3
Once you understand this mechanism, a lot can change. You are not hypochondriac. You are not dramatic. Part of your pain may have to do with a nervous system stuck in an alarm it can only switch off with difficulty on its own.
This is also why the fear of movement can become a pain driver in itself. In people who barely move out of fear, the deep stabilisers can weaken, connective tissue can lose glide, and the nervous system receives less movement input. That can make the system 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 describes: not pain alone, but also the fear of pain, catastrophising and avoidance may co-determine whether an acute back pain becomes chronic. It is an explanatory model, not a proven causal chain. A cross-sectional study in 276 patients with chronic low back pain found that catastrophising, movement fear and sex together could statistically explain around 35 percent of the differences in disability. That too is a snapshot, not evidence of a cause.
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. Also Doménech-Fernández J et al. Catastrophizing and fear avoidance beliefs in chronic low back pain: a cross-sectional study. Eur J Phys Rehabil Med. 2025;61(2):305 to 312. DOI: 10.23736/S1973-9087.25.08419-9
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 set a lot in motion
In 2021, JAMA Psychiatry published a study that triggered a great deal of discussion in pain medicine. The method under study is called pain reprocessing therapy. Roughly translated: reframing 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.
Important context: the trial enrolled people with primary, that is non-specific, back pain, where no physical cause had been identified. Average pain intensity was 4.1 out of 10 and average disability 23 out of 100. So this was a group with mild to moderate pain, not the most severe cases.
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. At one year the group difference was smaller but still present. In 2025 the same journal published a five year follow-up, but as a short research letter. A firm statement about durability across five years can only be drawn from it with caution.
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 in this one trial. That is a remarkable number, and so far it has been measured this way only once. There is no direct comparison with surgery, the two have never been randomised against each other. What this trial does show: a pain present for ten years on average can still change. And it can change through a neurobiological learning process, without scalpel, without injection, without pill.
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. After 26 weeks, 7 of 11 people in the PSRT group reported being pain free, compared with 3 of 12 under MBSR and 2 of 12 under usual care. Please read those numbers for what they are: a pilot study with eleven to twelve people per arm. Expressed as percentages they look larger than the data can carry. 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. At 26 weeks, 60.5 percent under MBSR and 57.7 percent under CBT reached a clinically meaningful functional improvement, compared with 44.1 percent in usual care. For MBSR the results stayed largely stable 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 have become a kind of memory of your nervous system. And memories can be worked with.
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.
I do not believe this is always 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 meta-analysis of 85 observational studies found: even one adverse childhood experience went with 29 percent higher odds of reporting chronic pain in adulthood (adjusted odds ratio 1.29). For context: with a common outcome an odds ratio overstates the actual risk, so the number shows a direction rather than an exact value. With four or more such experiences it was almost twice as high (aOR 1.95). For childhood physical abuse the figures were aOR 1.50 for chronic pain and 1.46 for pain-related disability. Every included study is observational and based on self-report. They show an association. They do not prove cause and effect.
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 its own authors call preliminary compared emotional awareness and expression therapy (EAET) with classic CBT in 53 older veterans with chronic musculoskeletal pain. Right after treatment, 41.7 percent of EAET patients had 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 the 30 percent threshold. The sample was old, on average 73 years, and 92 percent male. It does not transfer readily to younger people or to women. 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 noticeably quieter over time. Whether one caused the other, I cannot prove. I cannot claim this is the same for you, and I am not promising you this outcome. 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 movement and manual therapy, in my experience, often carry further when the nervous system is treated alongside.
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 can speak for an alert but calm vagus nerve. Low HRV can be a hint that your body is currently working a lot in protection mode. That is not certain: HRV values also depend on age, fitness, breathing rate, sleep, alcohol, infection, cycle and medication. So for me HRV is a trend measure over months and not a label.
A meta-analysis found high-frequency HRV to be moderately to markedly reduced on average in chronic pain. That may mean the brake pedal of the autonomic nervous system, the parasympathetic branch, is working at lower capacity. The body's own pain inhibition system could be dampened as a result. The authors point out themselves that heterogeneity between studies was high and that the result is heavily driven by fibromyalgia studies. For back pain alone the evidence is thinner.
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 pooled ten studies with 277 people in total. After structured exercise over four to 24 weeks, several HRV measures improved within groups, especially the vagally mediated values at rest. The authors stress that the number of high-quality studies is small and that the results should be read with caution. Exercise could therefore be more than "muscle building". It could also be training for the nervous system.
Meus T et al. Exercise and Heart Rate Variability in Chronic Musculoskeletal Pain: A Systematic Review. Sports Med Open. 2025;11(1):109. DOI: 10.1186/s40798-025-00916-8
In my practice on Skalitzer Strasse in Berlin, this is what we measure. A 24 hour ECG with HRV analysis gives an indication of how your autonomic nervous system is currently working. An indication, not a diagnosis: there is no generally accepted reference value for the individual case, and the influences named above move the value from day to day. This examination is usually a self-pay service. So I discuss beforehand what a result would actually change for you. The advantage: you get a number that can move, instead of only a feeling.
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. In laboratory and animal models they can activate mast cells and pro-inflammatory messengers and act on the nervous system. People affected report musculoskeletal complaints, neurocognitive symptoms, exhaustion. In a prevalence study of 236 ME/CFS patients with a history of mould exposure, 92.4 percent had detectable mycotoxins in urine. That study had no control group, and the authors themselves call their data preliminary. Mycotoxins are also taken in through food, so a urine finding on its own proves neither a mould burden in the home nor a cause of pain. For chronic back and neck pain there are no studies on this link so far.
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. The 92.4 percent figure comes from Wu T et al. Int J Environ Res Public Health. 2022;19(4):2052. DOI: 10.3390/ijerph19042052
Heavy metals such as mercury, lead, cadmium and arsenic can generate oxidative stress, displace essential trace elements like zinc and selenium, block enzymes and damage mitochondria. This is shown mostly in cells and in animal models. In a study of 41 metal industry workers with at least five years of occupational exposure, measurable abnormalities of the small nerve fibres were found compared with 36 controls, the fibres that transmit temperature and pain. This is high occupational exposure. It cannot be transferred to everyday exposure.
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 stubborn, then it can make sense to look at this layer. Honesty belongs here too: the value of such tests is debated among specialists, they are usually self-pay, and an abnormal result is not yet proof of the cause of your pain. So I discuss beforehand what a result would actually change. If it would change nothing, we do not measure it.
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?". Yes, in the moment of application. What happens afterwards is a counter-reaction of the autonomic nervous system. For chronic back and neck pain, though, this effect has not been studied.
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 review rests on nine papers from eight individual trials. The evidence base is therefore very small, the effects are plausible, and transfer to chronic back pain is not established.
Almahayni O, Hammond L. Does the Wim Hof Method have a beneficial impact on physiological and psychological outcomes? A systematic review. PLOS ONE. 2024;19(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 took my back pain away. I am describing a sequence in time: my nervous system settled, and everything else I was doing (therapy, posture work, relational work) could, in my view, land better afterwards. That is a single experience and not a recommendation, and for chronic back and neck pain this effect has not been studied. For you it may run completely differently.
I mean this seriously: cold exposure is not a harmless wellness extra. Cold shock can drive blood pressure and heart rate up abruptly, trigger cardiac arrhythmias and provoke an involuntary gasp. In open water this has caused deaths. Hypothermia also sets in faster than most people expect.
Not suitable, or only after medical assessment, with heart disease, cardiac arrhythmia, untreated high blood pressure, epilepsy, Raynaud's syndrome, cold urticaria, and during pregnancy.
And these rules always apply: never alone, never in deep or moving water, no hyperventilation before or during (it can cause loss of consciousness in water), never under the influence of alcohol, start short and build slowly. 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 is designed to bring people, step by step, into a more carrying alignment. It is not about exercises against the current pain. It is about changing your everyday loading patterns so that they challenge your pain system less often. Whether my programme achieves that is not tested in studies. It is my clinical experience from practice, not an established treatment path. 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. Two things belong to honesty here. For most of these remedies there are no large randomised trials in back pain. And plant-based does not mean harmless: such remedies can have side effects and can get in the way of the rest of your medication, for example blood thinners or antidepressants. In pregnancy, while breastfeeding, and with liver or kidney disease we look particularly closely. So I use them as a complement and not instead of a treatment whose effectiveness is established. And I discuss every remedy individually with you, with an eye on everything else you take.
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. Whether relieving this load changes back pain has not been tested in large trials. It is a physiological line of reasoning and my clinical experience, not an established treatment path.
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 can have less reserve against load, stress, and repair work. That is a physiological line of reasoning; for back pain itself this chain is not established. If laboratory testing shows a deficiency, it can make sense to balance it in a targeted way, for example iron, vitamin D, B vitamins or magnesium. That belongs in medical hands and not on the shelf: magnesium can become dangerous with impaired kidney function, iron with an iron storage disease, vitamin D at high doses over a longer period. That such a balancing also changes back pain is not established. Without a documented deficiency, supplementation does little according to current knowledge.
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 to place your pain differently. This explicitly does not mean "ignore it". The precondition is that a medical examination has ruled out dangerous causes. Once that is settled, when pain spikes you can tell yourself: this is my nervous system speaking up, and not necessarily new damage. That cognitive move can retrain your brain over time. It is the heart of what pain reprocessing therapy teaches. If a pain suddenly changes, is entirely new, or comes with the warning signs listed at the start of this article, this lever does not apply. Then you see a doctor.
Second lever. Breathe slowly and evenly for five minutes a day. Four seconds in, six seconds out, through the nose if possible. Slow breathing in this range is one of the ways in which you can consciously act on your autonomic nervous system. It costs nothing, and in studies it goes along with higher HRV in the short term. Whether that also changes your back pain is another question. Important: breathe slowly, do not hyperventilate.
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. If something comes up that overwhelms you, that is not failure. It is a good reason to get professional support.
Having less pain is not a luxury. It can be the precondition for being yourself again, instead of constantly playing gatekeeper inside your own body. I cannot promise you this freedom. What I can say: 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.
Sources
- Brinjikji W et al. Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations. AJNR Am J Neuroradiol. 2015;36(4):811 to 816. DOI: 10.3174/ajnr.A4173 [Systematic review, 33 studies, n=3110]
- Gugliotta M et al. Surgical versus conservative treatment for lumbar disc herniation: a prospective cohort study. BMJ Open. 2016;6(12):e012938. DOI: 10.1136/bmjopen-2016-012938 [Prospective cohort, n=370]
- Jacobs WCH et al. Surgery versus conservative management of sciatica due to a lumbar herniated disc: a systematic review. Eur Spine J. 2011;20(4):513 to 522. DOI: 10.1007/s00586-010-1603-7 [Systematic review]
- Hartvigsen J et al. What low back pain is and why we need to pay attention. The Lancet. 2018;391(10137):2356 to 2367. DOI: 10.1016/S0140-6736(18)30480-X [Series paper]
- Foster NE et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 2018;391(10137):2368 to 2383. DOI: 10.1016/S0140-6736(18)30489-6 [Series paper]
- Fan N et al. Neural correlates of central pain sensitization in chronic low back pain: a resting-state fMRI study. Neuroradiology. 2023;65(12):1767 to 1776. DOI: 10.1007/s00234-023-03237-3 [Cross-sectional fMRI study, n=112]
- Roussel NA et al. Central Sensitization and Altered Central Pain Processing in Chronic Low Back Pain: Fact or Myth? Clin J Pain. 2013;29(7):625 to 638. DOI: 10.1097/AJP.0b013e31826f9a71 [Narrative review]
- 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 [Model review]
- Ashar YK et al. Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial. JAMA Psychiatry. 2022;79(1):13 to 23. DOI: 10.1001/jamapsychiatry.2021.2669 [RCT with fMRI, n=151]
- Ashar YK et al. Pain Reprocessing Therapy vs Placebo and Usual Care: 5-Year Follow-Up. JAMA Psychiatry. 2025;82(10):1049 to 1051. DOI: 10.1001/jamapsychiatry.2025.1844 [Research letter, long-term follow-up]
- Donnino MW et al. Psychophysiologic symptom relief therapy for chronic back pain: a pilot randomized controlled trial. Pain Rep. 2021;6(3):e959. DOI: 10.1097/PR9.0000000000000959 [Pilot study, n=35, 11 to 12 per arm]
- Cherkin DC et al. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain. JAMA. 2016;315(12):1240 to 1249. DOI: 10.1001/jama.2016.2323 [RCT, n=342]
- 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 [Meta-analysis of observational studies, k=85 included, 57 pooled, n=826,452]
- Tidmarsh LV et al. The Influence of Adverse Childhood Experiences in Pain Management. Front Pain Res. 2022;3:923866. DOI: 10.3389/fpain.2022.923866 [Topical review]
- Lumley MA, Schubiner H. Emotional Awareness and Expression Therapy for Chronic Pain. Curr Rheumatol Rep. 2019;21(7):30. DOI: 10.1007/s11926-019-0829-6 [Review]
- Yarns BC et al. Emotional Awareness and Expression Therapy Achieves Greater Pain Reduction than Cognitive Behavioral Therapy in Older Adults. Pain Med. 2020;21(11):2811 to 2822. DOI: 10.1093/pm/pnaa145 [Preliminary randomised comparison trial, n=53, mean age 73, 92 percent male]
- 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 [Meta-analysis, k=51 included, 26 pooled, result heavily driven by fibromyalgia studies]
- Forte G et al. Heart Rate Variability and Pain: A Systematic Review. Brain Sci. 2022;12(2):153. DOI: 10.3390/brainsci12020153 [Systematic review, k=71]
- Meus T et al. Exercise and Heart Rate Variability in Chronic Musculoskeletal Pain. Sports Med Open. 2025;11(1):109. DOI: 10.1186/s40798-025-00916-8 [Systematic review, 10 studies, n=277]
- 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 [Meta-analysis of 15 cross-sectional studies]
- 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 [Randomised trial, n=66, two authors affiliated with the organisation promoting the tested method]
- Doménech-Fernández J, Ezzeddine Angulo A, Peñalver-Barrios L et al. Catastrophizing and fear avoidance beliefs in chronic low back pain: a cross-sectional study. Eur J Phys Rehabil Med. 2025;61(2):305 to 312. DOI: 10.23736/S1973-9087.25.08419-9 [Cross-sectional, n=276]
- 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 [Cross-sectional, n=512]
- Shahidi B et al. Differential effects of mental concentration and acute psychosocial stress on cervical muscle activity and posture. J Electromyogr Kinesiol. 2013;23(5):1082 to 1089. DOI: 10.1016/j.jelekin.2013.05.009 [Experimental, n=60]
- Ratnaseelan AM et al. Effects of Mycotoxins on Neuropsychiatric Symptoms and Immune Processes. Clin Ther. 2018;40(6):903 to 917. DOI: 10.1016/j.clinthera.2018.05.004 [Review]
- Wu T et al. Prevalence of Aspergillus-Derived Mycotoxins in ME/CFS Patients with Mold Exposure. Int J Environ Res Public Health. 2022;19(4):2052. DOI: 10.3390/ijerph19042052 [Prevalence study, n=236]
- Jomová K et al. Heavy metals: toxicity and human health effects. Arch Toxicol. 2024;98(1):153 to 209. DOI: 10.1007/s00204-023-03562-9 [Review]
- Koszewicz M et al. The impact of chronic co-exposure to different heavy metals on small fibers of peripheral nerves. J Occup Med Toxicol. 2021;16:12. DOI: 10.1186/s12995-021-00302-6 [Observational, 41 occupationally exposed metal workers and 36 controls]
- Almahayni O et al. Does the Wim Hof Method have a beneficial impact on physiological and psychological outcomes? PLOS ONE. 2024;19(3):e0286933. DOI: 10.1371/journal.pone.0286933 [Systematic review, 9 papers from 8 trials]
- Andersen TE et al. A randomized controlled trial of brief Somatic Experiencing for chronic low back pain and comorbid PTSD symptoms. Eur J Psychotraumatol. 2017;8(1):1331108. DOI: 10.1080/20008198.2017.1331108 [RCT, n=91]
This article is general information. It does not replace a medical examination, a diagnosis or treatment. Please do not stop prescribed medication on your own, and do not start any of the measures described without first checking the warning signs at the beginning of this article. In a medical emergency, call your local emergency number (112 in Germany, 999 in the UK, 911 in the US). If you are in serious emotional distress in Germany, Telefonseelsorge is free and available around the clock on 0800 111 0 111 or 0800 111 0 222.