The Pain Mechanisms of Chronic Low Back Pain

In simple terms, chronic low back pain is pain affecting the lumbar spine region that lasts
longer than three months. However, chronic low back pain is not simply acute (new) low back pain
that has failed to resolve. Rather, it often reflects an overlap of two or even three distinct pain
mechanisms, each of which may need to be addressed to achieve an optimal outcome: nociceptive,
neuropathic, and nociplastic pain.
Nociceptive low back pain arises from injury or irritation of non-neural tissues, including
muscles, ligaments, tendons, and joints. This type of pain is typically localized and may feel achy,
throbbing, or sharp with movement or certain positions. During a physical examination, a doctor of
chiropractic can often reproduce symptoms with palpation or specific movements. The term nonspecific low back pain is commonly used to describe pain that is predominantly nociceptive in
nature.
Neuropathic low back pain is caused by damage or disease affecting the nervous system
itself. In the context of chronic low back pain, this is most often associated with disk herniation
compressing a nerve root, degenerative changes (such as arthritis) narrowing the spaces through
which nerves travel, or postsurgical nerve injury. This form of pain is commonly described as
burning, shooting, or electric and often radiates along the course of the affected nerve. Patients may
also experience non-painful neurological symptoms, including numbness, tingling, weakness, or
altered reflexes.
Nociplastic low back pain typically develops over time in response to an initial injury or
episode of pain. This pain is characterized by altered pain processing within the nervous system and
is often associated with widespread or shifting pain patterns, heightened pain intensity, and increased
sensitivity to touch or movement. Patients with nociplastic low back pain may restrict movement and
daily activities out of fear of worsening their condition (kinesiophobia), describe pain in amplified or
distressing terms, feel poorly equipped to manage their symptoms, and commonly report poor sleep
and elevated stress. Coexisting conditions such as headaches, irritable bowel syndrome, or
fibromyalgia are also more prevalent in this population.
Because chronic low back pain often includes a combination of nociceptive, neuropathic, and
nociplastic components, treatment approaches must be individualized. A multimodal care plan may
include manual therapies, targeted exercises, physical modalities, and anti-inflammatory strategies
aimed at restoring normal motion and function to affected nerves, joints, muscles, tendons, and
ligaments. In addition, chiropractors may employ pain education and graded activity exposure to
address nociplastic factors and help patients regain confidence in movement. When appropriate,
referral to a medical physician or specialist may also be indicated—all with the goal of helping the
patient return to normal activities of daily living in the safest and most pain-free manner possible.

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