There is growing evidence that factors such as sleep disturbance, sustained high stress levels, depressed mood and anxiety are strong predictors of back or neck pain. This highlights growing evidence for the role that lifestyle and negative emotional factors play in sensitising spinal structures via the central nervous system. This may reflect clinically as a patient presenting with acute pain, reporting high levels of pain, distress and muscle guarding associated with a ‘minor’ mechanical trigger.

It is also important to note that negative beliefs about back or neck are predictive of pain intensity, disability levels and work absenteeism as well as chronicity. Beliefs that independently increase disability and impair recovery in an episode of pain are having a negative future outlook (e.g. ‘I know it will just get worse’) and believing that ‘hurt equals harm’ and that ‘movements that hurt should be avoided’ because of fear of pain and/or harm. There is also evidence that, in the absence of a clear traumatic injury, pain behaviours, such as limping, protective muscle guarding and grimacing, are more reflective of catastrophic thinking (e.g. ‘my back is damaged’, ‘I am never going to get better’ and ‘I am going to end up in a wheel chair’), fear and distress. These behaviours can result in abnormal loading of sensitised spinal structures, feeding a vicious cycle of pain. They are also linked to poor coping styles, such as avoidance and excessive rest, and leave the person feeling helpless and disabled. In contrast, people who have positive beliefs about back or neck pain and its future consequences are less disabled. In contrast to popular belief, there is little evidence that lower back pain is associated with a loss of ‘core’ or trunk stability. Rather, there is growing evidence that altered movement patterns and increased trunk muscle contraction are associated with the recurrence and persistence of back pain.