Alex Simotas, MD

Hospital for Special Surgery
Board Certified Physiatrist
Specializing In Spine & Sports Medicine

Home > Learning Center > Understanding Pain > A Look At The Cycle In Pain

A Look At The Cycle In Pain


Back pain can develop in a series of steps that can result in a vicious cycle.  Pain can become worse and worse in a pattern that seems unstoppable.

The good news is that this vicious cycle of back pain can be shifted by following a series of positive steps, leading instead to a cycle of wellness.

The Invisible Engine In Chronic Pain



Pain is an unpleasant sensory experience associated with harm or injury, or the threat of potential harm.

Pain functions as a warning signal. The nervous system senses danger and responds with certain actions referred to as guarding responses.  These guarding responses are designed to protect and defend us against further injury or harm.

The sensation of what you feel when experiencing back pain can vary widely.  You may experience things such as:

  • A gradual surge of tolerable to less tolerable discomfort
  • muscle cramping or severe spasms
  • overwhelming muscle fatigue
  • dense nerve like pounding
  • pins and needles
  • burning
  • sudden sparks of nerve like electricity

All of these are manifestations of stimulation of the pain system.



Guarding responses are part of the sensation of pain.  You may experience:

  • muscle tension
  • restrained movement
  • anxiety
  • fear of movement
  • sympathetic responses, which use adrenalin to raise your heart rate, blood pressure, and respiration

The purpose of these responses is to help you become aware of and escape quickly from harm.



When we experience pain and there is harm, injury or even the perceived threat of harm, the nervous system temporarily creates something called a low pain threshold (LPT) state.   When this occurs, we become supersensitive to pain in specific areas of the body.  Minor impulses or stresses to the region cause a lot of pain.



When there is a severe injury, this low threshold to pain works to our advantage. It becomes a built in safety mechanism.

A good example is what happens when you break a leg.  Messages received from the injured area cause a lowering of the pain threshold, resulting in an experience of intense pain, causing you to avoid movements that might result in greater harm.  As the fracture begins to heal, the pain threshold gradually returns to normal, allowing you to resume the use of your leg.



For reasons that are unclear, real pain sometimes occurs when there is an absence of injury, or at intensities much greater than a particular injury would suggest.  Real pain sometimes persists even after an injury has completely healed.  This appears to be the result of a persistent Low pain threshold (LPT).

This is true for some back pain. Many people suffer from chronic back pain when the actual degree of trauma or injury is small or undetectable.  One explanation would be the LPT phenomenon.  In this case, the sensation of pain and unchecked guard responses would create a low pain threshold (LPT) much longer than necessary.

This creates a vicious cycle.  Your response, the pain sensations produced, and a sustained LPT results in an experience of real pain well after the tissue has healed.



Pain is a fundamental function of our nervous system.  We need pain to work for us in the most advantageous way — to help protect us when we need it, and to diminish when we don’t.

Although pain occurs in an automatic part of nervous system, we are always filtering these experiences through the brain. Pain therefore is indirectly influenced by our beliefs, thoughts and emotions.

When we feel confident and positive, our low pain threshold is diminished.  When we feel apprehensive or anxious, our anticipation of harm will cause us to hold on to a LPT. Our goal is to find the balance between confidence and apprehension.



Pain centers in the spinal cord and brain are connected through a variety of pathways. The connections between them are not direct connections. This is why we cannot consciously turn pain on and off. However, we can use the anatomy of the nervous system connections between the brain and spine to gradually train our sensitivity to pain.

Pain Cycle With The Filtering System


How do our thoughts, beliefs and emotions influence our experience of pain? Let’s consider two different individuals with different thoughts and beliefs about pain.

One individual perceives that pain is relatively harmless and temporary.  He or she knows they can remain active without risking further injury. Their clinician encourages a perception of well-being and strength and minimizes the significance of an MRI finding.

In contrast, a second individual is concerned that pain is a sign of spinal instability and injury, and believes it should be closely monitored. This person is reluctant to bend for fear of re-injury, and moves with extreme caution. Well-meaning caretakers and friends unwittingly reinforce these beliefs with words of caution. (often the reasons for caution are unfounded and incompletely explained to the patient).  Fear may be reinforced by false positive readings from an MRI scan.



The second individual experiences their condition as a threat.  He or she is more apprehensive about the symptoms of back pain.  He or she continue’s to avoid activity, believing that activity may actually be harmful and will increase pain and sensitivity.  This leads to a downward cycle of:

  • deconditioning
  • weakness
  • increased anxiety
  • depression

Not everyone will suffer the consequences of back pain to the same degree. One individual may experience mild chronic back pain that only slightly hinders their activity. For another, the pain is much more severe and debilitating.

In a deconditioned state maintained by chronic pain, the pain sensitivity can be severe. Reversing this trend will be difficult to treat. Treatments often produce partial and unsatisfactory results.  But more comprehensive, and complete recovery is possible.  Recovery is often a longer and more difficult process.

No matter which individual is most similar to you, nearly everyone who has had some back pain has experienced this downward cycle of pain to some extent as illustrated in the chart below.

The Downward Cycle Of Pain




The mind-body connection is a series of complex neurophysiologic patterns that can help change the function of our body and mind.  The back pain cycle is one way of understanding how the Mind-Body response really works.



There are two key ingredients to the reversal of back:

  • A well adapted, properly informed and wellness-directed mind
  • A compliant and adequately performing body

Attitude alone will not change a pain-deconditioned state. Nor will exercise and stretching alone lead to such a change. It takes a positive and enlightened understanding of pain (See the articles: The Anatomy of Pain) and its interaction with the nervous system to support a cycle of recovery.



Recovery is rooted in positive perceptions of your spinal health. Adopting a healthy and strong image of your spine is critical to your recovery and well-being. I strongly suggest reading Understanding Spinal Degeneration to help dispel any possible misunderstandings about the causes of spinal degeneration and spinal and musculoskeletal injury.

Some things to remember:

  • Pain does not necessarily mean injury or harm.  Usually pain is better understood as a sensitivity that results from a temporary lowering of a pain threshold.
  • Exercise is safe. You can be active and not worry about hurting yourself.
  • Adopting “my spine is healthy” attitude becomes a foundation for a positive cycle of wellness, illustrated in the Recovery Cycle diagram below.

The Recovery Cycle