Why Back Pain Persists Despite Painkillers and Exercise

by Matthew Bennett

Persistent back pain doesn’t mean that you haven’t tried your best to manage it. You will quite probably have watched YouTube videos, done exercises and taken painkillers consistently, and still the aches come back.

Here at Sundial, our patients often ask us what they have been “getting wrong”. We can usually reassure them that they’ve been doing the right things but unfortunately persistent back pain is a sign that exercise and painkillers are not addressing the root cause of the pain.

Medication and exercise can only treat symptoms

When you are experiencing a flare up, it’s normal to turn to painkillers and anti-inflammatories to numb the pain. If you’re managing it by doing the right kind of exercises, these do indeed strengthen the back and support the spine. However, neither of these provide the answers you need about why your back hurts, what started it off or how to get better in the long term. Treating symptoms can’t resolve underlying causes.

Even a purely mechanical approach to back pain only provides partial answers. The Lancet did a study in 2018 (linked below) which concluded that the most effective approach for persistent back pain is an all-round biopsychosocial one. Sundial fully conforms to these recommendations. In other words, we investigate your individual case to diagnose and treat the cause of your particular pain, provide advice on how to manage it, suggest exercises to strengthen you and provide ongoing support to maintain progress.

Back pain has several causes. It isn’t one condition.

The cause of your back pain might not be obvious to you. It could lie within several different structures, invisible to you but traceable by a specialist. Yours might be originating in a disc bulge pressing on a nerve; or it might be inflammation sited in the facet joints or sacroiliac joint, affecting muscles or connective tissue surrounding the spine. Some causes become more likely to occur with age, while some might stem from injury or trauma,

The importance of a thorough examination was highlighted in a study which used precision diagnostic injections. These revealed exactly where pain was situated in the participating patients. The findings emphasised how it is not possible to isolate the cause of back pain by guessing from symptoms. This is why a thorough examination is necessary to work out how to help your persistent back pain. If we know the precise cause of the problem, we can treat it. Without that expertise, your back pain may just be experienced as a block of discomfort without a defined origin or an effective solution. Sundial chiropractors always aim to precisely diagnose the cause of your pain.

Your nervous system can change its pain pattern

The way your nervous system registers stimuli and how it is interpreted can shift, even after tissue has healed and apparently settled down. Matt Cunningham, our Pain Faculty Associate, provided us with some interesting context on this subject.

“We usually classify pain in three broad categories. At first, your pain is driven directly by inflamed or irritated tissue. This is called nociceptive pain and it is the normal response to an injury. It’s there to warn you. Next there’s neuropathic pain, where nerves are damaged or inflamed, sometimes sending pain signals spontaneously even when there’s no obvious stimulus. But it’s when repeated or prolonged pain signals ‘turn up the volume’ that we see the nervous system begin to interpret more things as painful. As time goes by, in some people, the whole pain system itself becomes more sensitive. This is called central sensitisation. Chronic low back pain can fall into this category. Pain killers and pushing on with exercises rarely shift this pattern and this is where Sundial’s biopsychosocial approach really comes into its own.”

Stronger painkillers may not hit the right target

Studies have shown that matching the right treatment to the symptoms is the most effective way to improve back pain. Stronger painkillers, surgery or injections are not necessarily the answer for your persistent back pain, even though you may feel you’ve exhausted all the usual avenues.

A large study in 2011 (the STarT Back Trial) looked at how targeting treatments according to their likelihood of developing long term conditions was what affected treatment outcomes the most positively. In the study, patients’ responses to a questionnaire were filtered to assign them to treatment groups, which ranged from minimal interventions (reassurance and advice) rising to physical and psychological therapy. When compared to the control group, who were patients receiving standard non-tailored one-size-fits-all approaches, the targeted treatment group showed much better improvements.

This ties in with our approach at Sundial. Our chiropractors and physiotherapists may ask questions about your job, lifestyle, mood or worries during your back pain assessment because this helps to get treatment exactly right for you.

What evidence supports the treatments at Sundial?

Spinal manipulation (the techniques used by chiropractors) has been shown to be one of the few conservative physical treatments which work. Only five back pain treatments for mechanical low back pain have sufficient evidence to support their use, and spinal manipulation is one of them. It consists of precise, controlled thrusts to joints, designed to move them safely beyond the “stuck” range which has been keeping you locked into back pain. It is thought to work by temporarily changing joint mobility and neuromuscular reflexes, which allows movement to become less guarded. This is a window of opportunity for you to move more freely, especially if you can sustain that improvement by sticking to your recommended home exercise plan.

Spinal mobilisation is a different technique which uses slower, rhythmic movements without the quick, firm adjustments of chiropractic manipulation. It improves joint mobility and reduces stiffness, having some of the same effects as manipulation but with more short-lived results. It is preferred by some patients because of its gentler, more massage-like sensations.

Flexion-distraction is a gentle, non-force technique that uses a specially designed table that can move and flex. During treatment, you lie face down on our flexion-distraction table whilst we apply controlled, rhythmic flexing motions to your spine. This technique literally opens up the spaces in your spine where the nerves are being compressed, providing immediate relief whilst promoting long-term healing. Studies assessing individuals who received flexion-distraction therapy found that they had significantly less pain after intervention compared with those who did basic exercises for chronic low back pain.

Pain alteration. A fascinating effect of the chiropractic adjustment is that it can set up an alteration in pain processing within the nervous system. This pain-relieving effect from a single session is measurable but relatively brief, so a programme of chiropractic care at Sundial always puts spinal manipulation within a broader plan of exercise, education and management.

What do we do if your back pain isn’t improving?

The Sundial approach is to find out what precisely is causing your back pain and to tailor your therapy to exactly what you need. If improvement is slower than we’d like, we take that as a signal that we don’t yet possess the full picture. So we would be likely to start by reassessing your symptoms, checking that the exercises you are doing are the right ones for you. We might check that there are no hidden lifestyle factors keeping you stuck, like a change of job or a new chair at home. Perhaps we might add in a complementary treatment like low level laser therapy , sports or deep tissue massage or referring you to our excellent physiotherapy team.

Frequently asked questions

Why does my back pain keep coming back even after physio or medication?

Usually because treatment has targeted general back pain rather than the specific structure or pain pattern involved. Discs, facet joints, sacroiliac joints and surrounding muscles can all produce similar symptoms but need different treatment. A shift in the underlying pain pattern can also mean something that used to help can stop working.

What is central sensitisation and could it explain my back pain?

It’s a change in how the nervous system processes pain signals, so pain persists or intensifies even once the original tissue irritation has settled. It’s more likely the longer back pain has been present. Clinical guidelines recommend working out whether pain is primarily tissue-driven, nerve-related or centrally sensitised, because each needs a different combination of treatment and pacing.

Can an MRI or X-ray tell me why my back pain isn’t going away?

Not on its own. Imaging rules out serious causes and shows structural changes, but findings like disc degeneration turn up in plenty of people who have no pain at all, so a scan can’t reliably pin down which structure is actually responsible. That’s usually worked out through a clinical assessment, movement testing, palpation, pain provocation, sometimes alongside imaging rather than instead of it.

Is it normal for back pain to last for months or years?

It’s common. That doesn’t make it permanent. Persistent back pain is often down to a mismatch between the treatment used and the actual source or pattern of the pain, not an unfixable underlying problem. Plenty of people improve substantially once a more targeted assessment and plan are in place.

Should I stop exercising if it isn’t helping my back pain?

No, generally. Stopping altogether rarely helps and can make things worse over time. What usually needs to change is the type, intensity or focus of the exercise, not whether you do it. A targeted assessment can identify what kind of loading and movement is likely to help your particular pattern of pain.

What treatments actually work for chronic back pain?

The evidence points to a combination rather than any single fix: manual therapy such as spinal manipulation, specific forms of exercise (Pilates, McKenzie-based exercise and functional restoration all have decent evidence behind them), and for longer-standing pain, multidisciplinary biopsychosocial rehabilitation combining physical treatment with psychological or work-focused support. Which combination suits you depends on your individual assessment.

About Matthew Bennett, Chiropractor Brighton

Matthew Bennett is the founder and principal chiropractor at Sundial Clinics Brighton, established in 1991. With over 35 years of clinical experience, Matthew qualified from the Anglo-European College of Chiropractic in 1987 and served as President of the British Chiropractic Association for four years. As a Fellow of the Royal College of Chiropractors and former team chiropractor for Brighton and Hove Albion FC and the British Alpine Ski Team, Matthew combines evidence-based chiropractic treatment with sports performance expertise. His authority in musculoskeletal health has been recognised through national media appearances, expert witness roles and contributions to professional publications. Matthew’s commitment to clinical excellence ensures patients receive the most effective chiropractic care in Brighton.