Stress and pain.
The powerful connection.
The relationship between stress and back pain is one of the most important breakthroughs in pain science in recent years. Stress, anxiety, and negative thoughts can amplify, sustain, and even cause pain. But the good news: these insights also offer powerful treatment options.
Groundbreaking studies
PRT Trial (JAMA Psychiatry, 2022)
Ashar et al. examined Pain Reprocessing Therapy (PRT) in 151 people with chronic back pain. After just 4 weeks of treatment, 66% of the PRT group was pain-free or nearly pain-free, compared to 20% in the placebo group. These results held up after 1 year of follow-up.
PRT teaches people to reinterpret their pain as a false alarm from the brain, rather than a sign of tissue damage. By reducing the fear of pain, the pain system can "switch off".
RESTORE Trial (Lancet, 2023)
Kent et al. examined Cognitive Functional Therapy (CFT) in 492 people with chronic low back pain. CFT combined pain education, gradual exposure to feared movements, and addressing lifestyle factors. Participants reported clearly fewer limitations in daily activities than with usual care, and their pain went down more too.
CFT proved not only more effective than standard physiotherapy, but also more cost-effective. The effects were sustained after 12 months.
PRT Trial
66%
Pain-free after 4 weeks of PRT
RESTORE Trial
12mo
Fewer daily limitations than usual care, still at 12 months
The fear-avoidance cycle
In many people with chronic back pain, a vicious cycle develops:
- 1Pain is experienced during movement or activity
- 2Catastrophizing: "My back is broken", "It will never get better"
- 3Fear and hypervigilance: constantly alert to pain signals
- 4Avoidance: movements and activities are avoided
- 5Deconditioning: muscles become weaker, mood declines
- 6More pain: the cycle repeats and reinforces itself
Practical tips
Mindfulness and meditation
Daily mindfulness (10-20 minutes) reduces pain, stress, and catastrophizing. The Mindfulness-Based Stress Reduction (MBSR) approach has proven effectiveness for chronic pain. Start with apps like Headspace or Calm, or find a course near you.
Breathing exercises
Slow, deep breathing activates the parasympathetic nervous system and reduces stress. Exhaling longer than you inhale is especially calming. Try it below: in for 4 counts, out for 6. Do this for 1-2 minutes when you feel pain or stress coming on.
In for 4 counts · out for 6 counts
Breathing exercise: breathe in for 4 counts and out for 6 counts, following the circle as it grows and shrinks.Graded exposure
Identify activities you avoid out of fear of pain. Gradually build these up again, starting with the least threatening. Discover that movement is safe and that the pain does not get worse as you feared. This breaks the fear-avoidance cycle.
Sleep hygiene
People who sleep badly for years are nearly twice as likely to end up with back pain that stops them working. That comes from a study of 8,601 people followed for around 22 years (Skarpsno et al., 2021). Note what was measured: not getting back pain, but back pain that puts you out of action. The hopeful part from the same study: among the bad sleepers, those who moved enough had just over a third less risk. Go to bed and get up at the same time every day, keep screens away for the last hour, keep the bedroom cool and dark, and go easy on caffeine after 2 pm.
Key message
Pain is a construction of the brain, not a direct measurement of damage. This does not mean that pain is “imagined”; it is 100% real. But it does mean that psychological factors have a powerful influence. With cognitive behavioural therapy and mindfulness there is still something to measure a year or two later, and for back pain that is unusual. Set your expectations accordingly: it comes to roughly 7 to 10 points on a pain scale of 100, so noticeable, but not a cure (Jenkins et al., 2025). PRT and CFT look promising, but each still rests on a single trial.
Next step