Low Back Pain: How To Turn Down the Volume

How Overcoming Fear & Anxiety Can Improve Your Function

Low Back Pain Volume Knob

Low back pain is the most common cause of disability in adults – 84% of people will experience low back pain at some point1. Without a doubt, you’ve tried at least one method to help relieve your low back pain – chiropractic, massage, ointments, opioids, braces, ice, heat, maybe even surgery. As time goes on and your pain continues, it’s understandable that you get discouraged. You may become worried that your low back pain might not improve.

I understand your concern.

This article is for you…

In Physical Therapy, I see people with low back pain every single day. Most people come in with a complaint that they strained their back a few weeks ago and it’s already getting better. Depending on the issue, I might help them with some treatment and exercises and the issue is resolved rather quickly.

“That’s great,” you say, “but why won’t my back pain go away?”

My hope is that, with a better understanding of Pain and how you experience it, you might find that there is hope for your low back pain, after all.

Understanding Pain 101

Maybe Your Back Is Normal

Do you believe the reason you have low back pain is because something is physically wrong with your back?

Maybe, you had an x-ray or MRI that confirmed you have some sort of ‘abnormality’ – arthritis or a bulging disc. Any natural response to these results would assume this diagnosis must be causing your pain – it’s right there in black and white.

Well, here’s a bit of interesting news…

32% of people WITHOUT PAIN have ‘abnormal’ lumbar spines on imaging studies2.

It gets even more interesting…

47% of people WITH LOW BACK PAIN have NO ‘abnormalities’ on imaging studies3.

Even when ‘abnormalities’ show up, we often can’t link the abnormality with your symptoms.

This evidence should come as good news to you. No longer do you have to dwell on your MRI results. No longer do you have to let fear sink in and lower your sense of well-being4. Fear can change the way your brain processes pain…

Central Sensitization: Your Nerves Are on High-Alert

If your low back pain began with an injury, the normal tissue-healing process takes place within a few weeks, in some cases up to a few months.

Why does pain sometimes persist beyond that?

The longer pain sticks around, your nerves can become more and more sensitive, effectively turning up the ‘pain volume knob’ in your brain.

This state of persistent hyper-excitability of your nerves can continue even after tissue healing has occurred5.

Now activities that aren’t causing you actual harm are perceived as painful. Normal, everyday tasks become threats – your ‘pain volume knob’ has got you on high-alert.

How does this happen? Why do some people get off easy and others are stuck with this chronic low back pain?

There is evidence that suggests fear plays a role in persistent pain6,7. Here are some factors that may lead to chronic low back pain:

– Presence of symptoms below the knee8,9
Psychological distress or depression10,11,12
Fear of pain, movement, and re-injury or low expectations of recovery13,14,15,16,17,18
– Pain of high intensity19
A passive coping style20,21,22

As you can see, only the first factor is physical, all others are mostly psychological. Again, this should come as good news to you – this means you have control over your outcomes.

Treatment Options to Turn the Pain Volume Down

Your brain’s ‘pain volume knob’ has been turned up.

Now it’s time to turn it down…

Stay Positive

Low Back Pain is common. Nearly everyone experiences it. Remember that the natural process of low back pain is positive – your body does an incredible job at healing.

Don’t overlook this.

Studies show that people who have positive expectations of recovery have better outcomes23,24.

Active Rehabilitation

One of the factors leading to chronic low back pain is a passive coping style. Maybe you’re of the mindset that it’s someone else’s job to ‘fix’ your pain and ‘heal’ you. Although healthcare professionals are, in large part, stellar in their knowledge and abilities, when it comes to low back pain, the best outcomes happen when you become an active participant in your recovery.

What does this look like?

First and foremost, you need to remain active. Even though a natural tendency is to rest and avoid movement, the opposite has been proven to be very effective25,26,27. Only when your brain begins to understand and believe that you can perform certain functions without causing harm will it start to turn down the pain volume.

This may take some time. It is a process. It may even cause an increase in pain at some points – expect that. But know that the longer you stick to it and the more functions you take part in, the better off you’ll be.

Graded Exposure and Activity

Think of a function you used to perform without a hitch that you now associate with your low back pain. Maybe it’s bending down to lift something off the ground.

Wouldn’t it be great to be able to bend and lift again?

Step 1 is to no longer think of this task – bending and lifting – as threatening. Instead, think of something positive associated with lifting, such as lifting a happy baby or discovering a hundred-dollar bill!

Rather than going for the glory and lifting heavy boxes day 1, let’s first break down the task into achievable, non-threatening steps28.

1. Supine Hip Flexion:

  • Lie on your back and slowly bend your right knee toward your chest
  • Repeat with the left knee
  • Continue slowly alternating

2. Seated Hip Flexion:

  • Sit in a chair and bring your right knee toward your chest
  • Repeat with the left knee
  • Continue slowly alternating

3. Mini Bends:

  • Stand with feet hip-width apart
  • Maintain a neutral spine
  • Bend forward at the hips and knees
  • Slide your hands down the front of your legs as you bend
  • Go down only as far as is comfortable and continue repeating
  • As you are able, begin to bend further and further down
  • Eventually, normal bending function should be restored

4. Light Aerobic Exercise:

  • Begin exercising at a low level
  • Try light walking
  • Walk only as long as you can tolerate
  • Slowly begin to increase the duration of your walks

As you can see, simple tasks become more complex over time as you can tolerate them. This allows graded exposure to non-threatening activities to lead to the functions you want to get back to.

In Summary:

  • You are in control over your outcomes
  • Low back pain has naturally good outcomes
  • Remain active
  • Begin to get back to the activities you want to perform

Always remember that you can turn down the pain volume.

Nothing is holding you back. Get started!

Question: What have you found to be most helpful in overcoming your low back pain? You can leave a comment by clicking here.


  1. Balague F, et al. Non-Specific low back pain. Lancet. 2012;379(9814):482–91.  ↩
  2. Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6:106–114.  ↩
  3. Savage RA, Whitehouse GH, Roberts N. The relationship between the magnetic resonance imaging appearance of the lumbar spine and low back pain, age and occupation in males. Eur Spine J. 1997;6:106–114.  ↩
  4. Modic MT, Obuchowski NA, Ross JS, et al. Acute low back pain and radiculopathy: MR imaging findings and their prognostic role and effect on outcome. Radiology. 2005;237:597–604. http://dx.doi.org/10.1148/ radiol.2372041509  ↩
  5. McAllister MJ. Central Sensitization. 2012. Available: http://www.instituteforchronicpain.org/understanding-chronic-pain/what-is-chronic -pain/central-sensitization. Last accessed 16th January 2016.  ↩
  6. George SZ, Fritz JM, Childs JD. Investigation of elevated fear-avoidance beliefs for patients with low back pain: a secondary analysis involving patients enrolled in physical therapy clinical trials. J Orthop Sports Phys Ther. 2008;38:50–58. http://dx.doi.org/10.2519/jospt.2008.2647  ↩
  7. George SZ, Fritz JM, McNeil DW. Fear-avoidance beliefs as measured by the fear-avoidance beliefs questionnaire: change in fear-avoidance beliefs questionnaire is predictive of change in self-report of disability and pain intensity for patients with acute low back pain. Clin J Pain. 2006;22:197–203  ↩
  8. Cherkin DC, Deyo RA, Street JH, Barlow W. Predicting poor outcomes for back pain seen in primary care using patients’ own criteria. Spine (Phila Pa 1976). 1996;21:2900–2907.  ↩
  9. Karjalainen K, Malmivaara A, Mutanen P, Pohjolainen T, Roine R, Hurri H. Outcome determinants of subacute low back pain. Spine (Phila Pa 1976). 2003;28:2634–2640. http://dx.doi.org/10.1097/01. BRS.0000099097.61495.2E.  ↩
  10. Cherkin DC, Deyo RA, Street JH, Barlow W. Predicting poor outcomes for back pain seen in primary care using patients’ own criteria. Spine (Phila Pa 1976). 1996;21:2900–2907.  ↩
  11. Pincus T, Burton AK, Vogel S, Field AP. A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain. Spine (Phila Pa 1976). 2002;27:E109–120.  ↩
  12. Ramond A, Bouton C, Richard I, et al. Psychosocial risk factors for chronic low back pain in primary care–a systematic review. Fam Pract. 2011;28:12–21. http://dx.doi.org/10.1093/fampra/cmq072  ↩
  13. George SZ. Fear: a factor to consider in musculoskeletal rehabilitation. J Orthop Sports Phys Ther. 2006;36:264–266. http://dx.doi.org/10.2519/ jospt.2006.0106  ↩
  14. George SZ, Fritz JM, Childs JD. Investigation of elevated fear-avoidance beliefs for patients with low back pain: a secondary analysis involving patients enrolled in physical therapy clinical trials. J Orthop Sports Phys Ther. 2008;38:50–58. http://dx.doi.org/10.2519/jospt.2008.2647  ↩
  15. George SZ, Fritz JM, McNeil DW. Fear-avoidance beliefs as measured by the fear-avoidance beliefs questionnaire: change in fear-avoidance beliefs questionnaire is predictive of change in self-report of disability and pain intensity for patients with acute low back pain. Clin J Pain. 2006;22:197–203.  ↩
  16. Karjalainen K, Malmivaara A, Mutanen P, Pohjolainen T, Roine R, Hurri H. Outcome determinants of subacute low back pain. Spine (Phila Pa 1976). 2003;28:2634–2640. http://dx.doi.org/10.1097/01. BRS.0000099097.61495.2E  ↩
  17. Kuijer W, Groothoff JW, Brouwer S, Geertzen JH, Dijkstra PU. Prediction of sickness absence in patients with chronic low back pain: a systematic review. J Occup Rehabil. 2006;16:439–467. http://dx.doi.org/10.1007/s10926–006–9021–8.  ↩
  18. Steenstra IA, Verbeek JH, Heymans MW, Bongers PM. Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature. Occup Environ Med. 2005;62:851–860. http://dx.doi.org/10.1136/oem.2004.015842  ↩
  19. Karjalainen K, Malmivaara A, Mutanen P, Pohjolainen T, Roine R, Hurri H. Outcome determinants of subacute low back pain. Spine (Phila Pa 1976). 2003;28:2634–2640. http://dx.doi.org/10.1097/01. BRS.0000099097.61495.2E  ↩
  20. Jones GT, Macfarlane GJ. Epidemiology of low back pain in children and adolescents. Arch Dis Child. 2005;90:312–316. http://dx.doi. org/10.1136/adc.2004.056812  ↩
  21. Ramond A, Bouton C, Richard I, et al. Psychosocial risk factors for chronic low back pain in primary care–a systematic review. Fam Pract. 2011;28:12–21. http://dx.doi.org/10.1093/fampra/cmq072  ↩
  22. van der Hulst M, Vollenbroek-Hutten MM, Ijzerman MJ. A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitation-or, back school treatment outcome in patients with chronic low back pain. Spine (Phila Pa 1976). 2005;30:813–825.  ↩
  23. Burton AK, Waddell G, Tillotson KM, Summerton N. Information and advice to patients with back pain can have a positive effect. A randomized controlled trial of a novel educational booklet in primary care. Spine (Phila Pa 1976). 1999;24:2484–2491  ↩
  24. Godges JJ, Anger MA, Zimmerman G, Delitto A. Effects of education on return-to-work status for people with fear-avoidance beliefs and acute low back pain. Phys Ther. 2008;88:231–239. http://dx.doi.org/10.2522/ ptj.20050121  ↩
  25. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–491  ↩
  26. Dahm KT, Brurberg KG, Jamtvedt G, Hagen KB. Advice to rest in bed versus advice to stay active for acute low-back pain and sciatica. Cochrane Database Syst Rev. 2010;CD007612. http://dx.doi.org/10.1002/14651858.CD007612.pub2  ↩
  27. Hagen KB, Hilde G, Jamtvedt G, Winnem M. Bed rest for acute lowback pain and sciatica. Cochrane Database Syst Rev. 2004;CD001254. http://dx.doi.org/10.1002/14651858.CD001254.pub2  ↩
  28. Moseley GL, Nicholas MK, Hodges PW. A randomized controlled trial of intensive neurophysiology education in chronic low back pain. Clin J Pain. 2004;20:324–330.  ↩
Get Your FREE eBook!
Why You Have Bad Posture and How To Make It Better
In addition, I'll send you one email per week with a link to new content. No Spam, I promise

Please note: I reserve the right to delete comments that are offensive or off-topic.