Jenny’s back pain usually settles within a few weeks. This time, 12 weeks have passed and it still intrudes on her life. Getting dressed hurts. Sitting through work is difficult. And something else is becoming harder to ignore: worry.
Authors
- Dave Newell
Professor of Integrated Musculoskeletal Care and Head of the Centre of Pain and Active Inference Research, Health Sciences University
- Giacomo Rossettini
Musculoskeletal physiotherapist, School of Physiotherapy, University of Verona
- Jorge Esteves
Visiting Professor, Centre for Pain and Active Inference (PAIn) Research, Health Sciences University
Why hasn’t it gone away? Is something seriously wrong? Will it ever get better?
Social media offers plenty of alarming possibilities. Jenny starts monitoring every twinge. Each painful movement seems to confirm that something must be wrong.
Jenny is fictional, but her experience may be familiar. When she consults her doctor, she might expect relief from exercise, medication or hands-on treatment. Could the consultation itself also influence her pain?
Imagine two versions of Jenny’s appointment. In one, the doctor interrupts her and describes her back as “worn out”. Jenny leaves with exercises, but also with a disturbing picture of a fragile spine.
In the other, the doctor listens, explores her concerns and examines her carefully. Finding no signs suggesting a serious underlying cause, they explain what they have assessed, acknowledge how disabling her pain is and discuss a manageable plan.
Both appointments might include the same exercises, but Jenny may leave with different expectations about her back.
Researchers call these surrounding influences “contextual factors” . They include expectations, past experiences, the doctor’s communication and the care setting.
Studies suggest these factors are linked to treatment outcomes. In one study involving 182 people with longstanding back pain, a stronger relationship with their physiotherapist early in treatment was associated with better outcomes after eight weeks.
Another UK study involving 960 patients receiving physiotherapy, osteopathy or acupuncture found that the relationship between patient and practitioner was among the strongest predictors of reduced disability. Agreement about treatment goals and how to achieve them was particularly important.
These observational studies cannot establish that the relationship caused improvement, but they suggest that what happens during a consultation deserves attention.
How words can influence pain
If Jenny’s pain is in her back, how could someone’s manner or explanation influence it?
Pain is not a straightforward measure of damage: its intensity does not always match the extent of tissue injury .
One possible explanation comes from predictive processing theories . These suggest that the nervous system interprets signals from the body alongside previous experiences, expectations and present circumstances.
For Jenny, pain that once meant “another episode that will settle” may now mean “something dangerous that nobody has identified”. This change in expectation could contribute to her pain feeling more threatening.
This is one possible explanation of persistent pain. It does not mean Jenny has consciously caused her symptoms.
There is experimental evidence that expectations can influence pain. In one study , healthy volunteers received a powerful opioid painkiller while experiencing painful heat. Positive expectations roughly doubled the drug’s pain-relieving effect, while negative expectations abolished it.
The drug was still being delivered, but participants received different information about it. Brain scans also showed changes in activity in regions involved in processing pain.
This suggests that expectations can influence pain through measurable biological processes. However, findings from short laboratory experiments cannot tell us exactly how much a particular consultation will affect someone with longstanding back pain.
Giving reassurance something to stand on
Simply saying “there’s nothing wrong” is unlikely to address Jenny’s experience. Something plainly is wrong: she hurts, cannot do what she normally does and wants to understand why.
A useful explanation would acknowledge this while distinguishing pain from evidence of serious disease. It would explain the assessment and give Jenny opportunities to ask questions.
The doctor might also ask what she fears. Perhaps her main worry is that bending will damage her spine. Exercises alone may leave that concern untouched.
A theory called “active inference” offers another way to understand this. It proposes that expectations influence what people do, while their actions provide new information that can change those expectations.
In a 2026 paper applying this approach to pain affecting muscles and joints , researchers suggest that movement, communication and other aspects of care may help patients develop different expectations about their bodies.
If Jenny expects bending to cause damage, she may avoid it. With appropriate clinical guidance, gradually exploring that movement could help her discover that her back is more capable than she feared.
This theory may help explain how care works, but researchers have not shown that applying it improves outcomes beyond existing treatments. Treatments also have specific effects that cannot be explained by context alone.
Context has limits
A reassuring consultation cannot replace appropriate assessment or effective treatment, repair an injury or guarantee recovery. Nor does the importance of context justify offering unproven treatments simply because they are delivered with a good bedside manner.
Patients should never be blamed for continuing pain or told they need to think positively.
For doctor, the practical message is to combine careful assessment and evidence-based treatment with explanations that inform without creating unnecessary alarm. UK clinical guidance supports shared decisions, advice about remaining active and individually appropriate treatment for lower back pain.
Patients can reasonably ask what might be causing their pain, whether there are signs of anything serious and what activities they can safely continue.
Jenny needs her pain taken seriously, her concerns heard and a credible way forward. The way that care is offered may help shape what happens next, including her confidence in moving and managing pain.
