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How Depression & Anxiety Are Overlooked in Chronic Low Back Pain

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With our MIM Chronic Low Back Pain MasterClass coming up, I wanted to hit on a topic that you will almost NEVER hear discussed in fitness circles and to be honest, just as rarely in physical therapy. The reason is probably that most people in fitness and physical therapy think there is nothing they can really do about this issue of chronic low back pain. I get it, years ago I would have thought the same, this was WAY out of my scope of practice. Now though, I have such a greater appreciation that not only does this issue play a MAJOR role in chronic low back pain, but there are things that can be done IN fitness and physical therapy that can help!

That is the relationship of depression and anxiety with chronic low back pain. To be honest, the relationship can be complicated and it can be a bit of a “chicken or the egg” scenario many times. However, there is A LOT of research showing that depression and anxiety play a bit part in chronic low back pain.

How powerful is the relationship? Let’s look at a few eye opening studies…

-In a study of over 1,000 Canadian university students (rather young individuals) they found, “Over 50% of subjects reported low back pain across grades, and both depression and somatization were significantly positively associated with low back pain. Several positive associations between the cooccurrence of somatization and depression with various grades of low back pain were observed.” (1)

-A systematic review (a review of many different studies) found, “the findings of this systematic review suggest that depression might have an adverse effect on the prognosis of low back pain.” (2)

-Another review of multiple studies examined this issue and said, “It is argued that, in patients with clinical levels of depression, treatment modalities specifically targeting depressive symptomatology deserve serious consideration as an integral component of pain management programs.” (3)

-This study of over 2,000 people concluded, “Psychological distress such as anxiety, depression, and somatization (14.9% versus 8 were significantly higher in LBP patients.” (4)

I could pull a Captain America and literally do this all day! In fact, a quick search of depression and chronic low back pain pulls up over 3,000,000 citations on the subject. So, this isn’t something “new age” or way outside the box. In fact, some of the research is 30-40 years old, so why are we so often not told of this relationship?

Obviously there are some that are, but mental health is challenging and we don’t have a health care system in the U.S. that usually combines orthopedic and psychological treatments. Even though those with chronic pain have double the chances of committing suicide (5).

Why is this relationship so prevalent? The first is a relatively easy answer, when you have depression you are less likely to exercise, eat nutritious foods, socially interact, sleep well, and perform healthy habits. This can all lead to issues of low back pain, but it also goes deeper and is a bit more complex.

As described in the journal of Neuroscience and Biobehavioral Reviews, “the neurons in the spinal cord and the brain respond with neuroplastic changes (Bannister and Dickenson, 2016). This maladaptive response may change the perception of pain to the point of feeling unbearable pain due to a simple caress (Bush, 2011). The maladaptive changes include abnormal threshold to stimuli, altered sensibility in receptors, ectopic generation of action potentials, reduced inhibition, and inappropriate connectivity of neurons.”

chronic low back pain

WHEW! What does that mean? The simple translation is that our body learns about this new state and starts to misread the information as danger. When we realize that injury sensory pathways of body pains have been shown to share the same brain regions involved in mood management, we can start to see how depression and anxiety can have a pretty strong relationship with chronic low back pain. That is why it is staggering to see stats show that up to 85% of chronic low back pain has no structural source! So, what can a fitness professional or physical therapist do?!

This Isn’t Just About Science

The big reason I wanted to discuss this topic was because especially after my 6th and 7th spinal surgeries (my disease is NO JOKE!) that were both very intense, I found myself with rather severe PTSD, depression, and anxiety. There would be nights I couldn’t sleep and would be shaking quite intensely from these issues (that was some of the lighter side of things). My pain doctors could really only offer anti-depressants (which is not uncommon) to my issues. So desperate, I tried them, but had very little impact on how I was feeling.

If I am being honest, the way I was able to finally manage a lot of these symptoms wasn’t just one thing. More and more the medical community is becoming aware that chronic pain typically requires a multidisciplinary approach that also uses mental health professionals as part of the treatment. I don’t want to misrepresent anything I am about to share as “the magic pill” because it works best in conjunction with other things and the results don’t happen overnight.

So, What Can Fitness & Physical Therapy Do?

It is not uncommon for people with chronic pain of any sort, but especially chronic low back pain to suffer from kinesiophobia (fear of movement). There are a number of reasons for this, but I can tell you from living it that the fear of increasing one’s pain is VERY real. Even though it is known that exercise can help symptoms of chronic low back pain, there is such a fine line in doing too much or not knowing how your body is going to respond to a form of exercise that this fear is very legitimate. So, how can we start helping people deal with their pain while they are in such a heightened state?

In recent years attention to diaphragmatic breathing and chronic low back pain has grown quite a bit. Many studies have shown that diaphragmatic breathing can help lower pain intensity in chronic low back pain. This is not only done because such breathing trains the very deep stabilizers of the core (like the diaphragm, transverse abdominis, pelvic floor, and others), but it also puts us in a more parasympathetic state (this is more of the rest and digest rather than fight or flight state). Teaching such methods can be a simple way to start building not just ways to help reduce symptoms, but to also empower the individual to manage their health on their own.

There is also strong evidence that meditation, mindfulness, and yes, exercise can all help these symptoms too, but is there a way to make it more specific to our chronic pain and to help manage our time (people in chronic pain can’t train very long and often suffer from things like brain fog as well, so being efficient with time is key).

A powerful option is what is known as Meditative Movement training. Meditative Movement is defined as “forms of exercise that use movement in conjunction with meditative attention to body sensations, including proprioception, interoception, and kinesthesis.”

This 2013 study highlights some of the many benefits of Meditative Movement training such as…

-Improvements on health-related quality of life (HRQOL) measures.

-Can be just as effective of a treatment for depression as anti-depressant drugs.

-The mindfulness aspect is believed to be one of the differences in how such practices create superior results from other forms of exercise.

-There is a very strong relationship with increased stress management including reduced anxiety as well.

-Then we have other physical benefits such as increased strength, balance, flexibility, and even aerobic conditioning. (6)

So, what is a simple example that people with chronic low back pain might start with (***ALWAYS CONSULT WITH YOUR DOCTOR BEFORE USING THESE IDEAS)?

Save 25% off our Online Certifications/Courses (like our Myofascial Integrated Movement & Breath Courses HERE), Ultimate Sandbags/Water Bags, and DVRT Workout programs this week with code “fall25” HERE



  1. Robertson D, Kumbhare D, Nolet P, Srbely J, Newton G. Associations between low back pain and depression and somatization in a Canadian emerging adult population. J Can Chiropr Assoc. 2017 Aug;61(2):96-105. PMID: 28928493; PMCID: PMC5596967.
  2. Pinheiro, Marina B., et al. “Symptoms of depression as a prognostic factor for low back pain: a systematic review.” The Spine Journal 16.1 (2016): 105-116.
  3. Sullivan, Michael JL, et al. “The treatment of depression in chronic low back pain: review and recommendations.” Pain 50.1 (1992): 5-13
  4. Bener, Abdulbari, et al. “Psychological factors: anxiety, depression, and somatization symptoms in low back pain patients.” Journal of pain research (2013): 95-101.
  5. U.S. Pain Foundation
  6. Abbott R, Lavretsky H. Tai Chi and Qigong for the treatment and prevention of mental disorders. Psychiatr Clin North Am. 2013 Mar;36(1):109-19. doi: 10.1016/j.psc.2013.01.011. PMID: 23538081; PMCID: PMC3917559.