Chronic back pain is not just a symptom that lasts longer than three months; it is a complex disorder of the neuro-immune system that gradually “recalibrates” pain pathways from the periphery to the spinal cord and brain. A new understanding of these pathways and the development of smart, personalized therapies are bringing us closer to a time when we will be able to sustainably suppress pain and restore function in some patients, with fewer side effects than ever before.

Why chronic back pain is so common and persistent

In terms of burden, chronic pain is among the leading causes of suffering and reduced work capacity in developed countries. In the United States, data from national health surveys show that a substantial proportion of adults have experienced chronic pain in the previous three months, and a significant portion has so-called “high-impact chronic pain” that limits daily activities. Although the numbers vary depending on the definition and methodology, the scale is sufficient to classify chronic back pain as a major public health challenge.

The uniqueness of the lower back lies in its role as an anatomical crossroads of forces: it bears the weight of the torso, absorbs every step and movement, and transmits loads to the pelvis and hips. Consequently, the reasons for pain vary—from degenerative changes of the disc and small joints of the spine, through spinal stenosis and nerve root compression, to muscular dysfunction, myofascial pain, and, more rarely, systemic rheumatic diseases. In some people, despite detailed examinations, no clear structural cause is found; this does not mean that “it's nothing,” but rather that the problem likely lies in functional changes within the nervous system.

From acute to chronic: how the brain and spinal cord “learn” pain

Acute pain, for example after a strain, usually subsides within a few weeks. But sometimes, during the recovery phase, a “turn” occurs: sensory fibers in peripheral nerves become more excitable, neurons in the spinal cord amplify signal transmission, and communication between brain areas responsible for sensation, emotions, and cognitive processes changes. We call this process maladaptive neuroplasticity.

The consequence is that the pain no longer reflects the condition of the tissue but becomes a separate, self-sustaining signaling pattern. In practice, this means that in some patients, even after the initial injury has healed or the inflammation has subsided, a constant, dull, or stabbing pain persists, sometimes with increased sensitivity to touch, cold, or movement. In addition, centers for mood and attention gradually become involved: pain disrupts sleep and concentration, fosters anxiety and depressive symptoms, and creates a vicious cycle of inactivity and even more pain.

What this means for diagnosis and therapy

The standard definition of chronic back pain refers to symptoms lasting longer than three months. But it is crucial to understand that the same clinical label hides different mechanisms; therefore, there is no single “magic bullet.” In practice, non-pharmacological and pharmacological measures are combined, and, if necessary, interventional procedures are used.

The hierarchy of treatment: from conservative to targeted

• Patient education and activation. Understanding that movement is safe and desirable, even when there is pain, is the first step. Self-help programs and quality educational platforms can reduce fear of movement (kinesiophobia) and relieve the burden on the system.


• Physiotherapy and supervised physical activity. Individually dosed core stabilization training, hip and thoracic spine mobility exercises, and aerobic activity have been proven to contribute to function.


• Complementary methods. Acupuncture, cognitive-behavioral techniques, and, in selected patients, mind–body approaches can have additional value.


• Medications. Nonsteroidal anti-inflammatory drugs and muscle relaxants are considered for short-term use; antineuropathic drugs (e.g., serotonin-norepinephrine reuptake inhibitors) target the neural component of pain. Opioids are no longer a first-line therapy and are reserved for clearly defined situations, under strict supervision.


• Interventions. In cases of radiculopathy or pronounced inflammation, targeted epidural or facet blocks are applied. If long-term, therapy-resistant pain with neuropathic features is present, neuromodulation is considered—primarily next-generation spinal cord stimulation (SCS) with modern, adaptive (closed-loop) devices.

Neuromodulation: how to “recode” pain signals

Spinal cord stimulation (SCS) has been helping some patients with chronic back and leg pain for decades. The latest generation of systems can read electrical responses from the spinal cord and adjust the output on the fly, which reduces discomfort when changing positions and can improve the consistency of analgesia. In recent meta-analyses, various SCS modalities have shown, on average, better outcomes than medication therapy alone for treatment-resistant chronic pain, across several clinically important measures (pain intensity, function, satisfaction with therapy).

In parallel, deep brain stimulation (DBS) and other targeted brain stimulation techniques are experiencing a breakthrough. Research groups—including teams from American universities like UCSF—have developed prototypes of personalized, closed-loop DBS: in chronic pain, they did not continuously activate stimulation, but instead used implanted electrodes to first “read” brain signal patterns associated with stronger pain, and then activated stimulation only when these patterns exceeded a set threshold. This approach saves energy, potentially reduces side effects, and, most importantly, targets the very moments when pain escalates. More on the principles of such therapy can be found in educational materials from health agencies and research programs, for example here.

What the latest findings from the lab and clinic tell us

In recent years, studies have been published in which neuroscientists identified biomarkers of chronic pain in deep brain structures and the cortex, and showed that subjective pain intensity can be predicted from these signals. In recent clinical trials on small groups of participants, personalized closed-loop DBS led to a significant reduction in pain compared to sham treatment, where the best target region in the brain (e.g., cingulate, insula, or thalamic circuits) was individually mapped, and then the dose and activation thresholds were titrated.

At the same time, reports with extended follow-up have emerged in the field of SCS, demonstrating the sustainability of the effect of sophisticated stimulation schemes—including protocols that rely on evoked potentials from the spinal cord itself to dose stimulation more precisely. This is important because some earlier studies did not report lasting benefits after the first year, so longer-term data are crucial for realistically informing patients.

Can all of this be available without surgery

Non-invasive brain stimulation methods such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), and, in more recent research, low-intensity focused ultrasound are also generating great interest. Although the findings are heterogeneous, systematic analyses suggest that properly selected protocols can short-term reduce pain intensity and improve function in some patients. The challenge is to standardize targets and dosages and to better discern which patient subgroups benefit the most.

In an ideal scenario, insights from invasive “closed-loop” systems—where the device learns to recognize brain patterns of pain—will be transferred to non-invasive platforms. This would enable personalized, time-dosed activation of stimulation in real-world conditions, without electrode implantation. Several multidisciplinary teams are already developing prototypes of such solutions.

The role of movement, sleep, and behavioral interventions

Even the most advanced technology cannot replace the fundamental habits that protect the spine and nervous system. Recently, walking has been particularly highlighted as an accessible, inexpensive, and effective activity. A large cohort analysis using motion-tracking devices suggests that a higher daily “walking volume” is associated with a lower risk of developing chronic low back pain over several years of follow-up. It appears that the amount of walking itself has a more important effect than the intensity of the walk, although faster walking also brings benefits. Details of the analysis and methodology are available in publicly accessible summaries of peer-reviewed journals, for example here.

For those who already have pain, programs of gradually increasing activity—for example, 10 to 15% more total steps per week—can be a realistic start. Core stabilization exercises (plank, “dead bug,” side plank), targeted strengthening of the glutes and deep core muscles, and breathing exercises that engage the diaphragm and relax the paraspinal musculature are important pillars. More intensive yoga or Pilates programs can contribute to stability and proprioception, with clear limits and expert supervision.

Sleep and psychological approaches are not an “add-on,” but a therapy: cognitive-behavioral techniques, mindfulness training, and proper sleep hygiene (a consistent bedtime, a moderately cool room, reduced afternoon caffeine intake) reduce the lowered threshold for painful stimuli.

How doctors choose therapy in practice

In the clinic, the starting point is not a single diagnosis, but the patient's profile: age, duration and pattern of pain (mechanical, neuropathic, inflammatory), neurological status, comorbidities, expectations, and motivation for active participation in treatment. This is followed by a stratified plan with clear goals for 4 to 8 weeks: to increase walking distance and time without an increase in pain, improve flexion and extension, reduce the need for “rescue” analgesics, and normalize sleep.

If there is no satisfactory progress after the initial cycle, other means are introduced: changing the type of exercise, combining it with acupuncture or a stress management program, a short pharmacological cycle, or, in the case of radiculopathy, a targeted intervention under X-ray guidance. Only if a persistent neuropathic component with functional limitations still dominates is neuromodulation considered. Before SCS implantation, a trial phase is mandatory to verify realistic pain relief in real-life situations.

What's next: from biomarkers to personalization

Advances in artificial intelligence and wearable technology (motion sensors, heart rate, heart rate variability) open up the possibility of digital biomarkers that will distinguish between “good” and “bad” days, predict exacerbations, and timely suggest micro-interventions: a short set of exercises, a break from sitting, a medication reminder, or the activation of non-invasive stimulation.

In clinical research, closed-loop DBS and SCS are going a step further: the devices simultaneously read and stimulate neural activity, creating a circular feedback loop. Clinicians thus obtain objective signals that accompany subjective pain reporting, and therapy can be dynamically adjusted—more stimulation during moments of worsening, less in phases of remission. In some protocols, double-blind testing of real and sham stimulation is already being conducted, thereby raising the level of evidence.

Practical advice for readers

• If pain lasts longer than 12 weeks or returns in frequent episodes, seek a medical evaluation to rule out red flags (difficulty with bladder/bowel control, progressive leg weakness, fever, unexplained weight loss).


• Start with a walking routine that you can maintain every day. For example, if you currently walk about 4,000 steps, set a goal of 4,500–4,800 for the next week and gradually progress.


• Include short blocks of core stabilization exercises 3 to 4 times a week under expert guidance. The focus on technique is more important than the duration.


• Talk to a therapist about workplace ergonomics: the height of your chair and monitor, foot position, and scheduling short breaks every 30–45 minutes.


• If a more invasive procedure is suggested, ask about the expected outcomes, the trial phase, risks, and the possibilities of tailoring the therapy to your pain profile.

Open questions and realistic expectations

Despite promising advances, several topics remain open. First, chronic back pain is not a single entity: patients with a pronounced neuropathic component likely respond differently to therapies than those with primarily mechanical pain. Second, the outcome depends on a package of measures—no single therapy “erases” all problems on its own. Third, and no less important, personal preferences, comorbidities, and socioeconomic conditions strongly determine the ability to adhere to the plan.

Research communities are therefore increasingly using adaptive trial designs in which therapy is adjusted over time to the individual's response. Within this framework, objective signals from the nervous system, behavioral and environmental data, and subjective reports are combined into a unique model that guides clinical decision-making—from changing medication, to intensifying exercises, to implementing neuromodulation.

Where to find verified information and professional help

Patients and readers who want to understand the “science of pain” more deeply can find information on verified websites of health institutions and universities. For insight into modern neuromodulation technologies and criteria for candidate selection, it is useful to review materials from leading pain and neurosurgery centers and summaries of clinical studies. Current trials of closed-loop DBS and SCS are available through public registries, and research results from the fields of walking, physical activity, and non-invasive stimulation methods are regularly published in open-access peer-reviewed journals. Clinical trial registries and review articles can help in understanding the direction in which the field is moving, with the note that therapeutic decisions are always made individually, in consultation with a doctor and a physiotherapist.

Editor's note: All time references and figures are consistent with data available as of October 3, 2025.