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August 24, 2026
Christine Bürg
Back pain can persist even when the original cause no longer fully explains the symptoms. Physiotherapist Nils Stützer explains what stress and anxiety have to do with it – and how to break the pain cycle
An interview with
Nils Stützer
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Back pain is one of the most common complaints there is. Yet what shows up on an MRI scan does not always explain how much a person is actually suffering. Stress, anxiety, lack of sleep, and emotional burdens can all shape how pain is perceived and contribute to it becoming entrenched.
With chronic back pain in particular, it is worth looking beyond muscles, discs, and the spine. Physiotherapist Nils Stützer explains in an interview what role the mind plays, why fear of movement can perpetuate symptoms, and what it takes to break out of this cycle.
Mr. Stützer, do you get the impression that stress and psychological burdens are becoming a more frequent problem for your patients today than they were in the past?
In my view, psychosomatic factors have always played an important role. As far back as 1977, psychiatrist George L. Engel developed the biopsychosocial model, which was adopted by the World Health Organization (WHO) in 2001 as part of the ICF (International Classification of Functioning, Disability and Health).
This model considers not only the illness and its physical causes, but also takes psychological and social factors into account, along with an individual's personal contextual factors. All of these can significantly influence the onset, perception, and progression of a structural disorder.
Social pressure has noticeably increased in recent years. Our society has long been driven by the motto "faster, higher, further," which was already generating high levels of stress. Today, existential burdens are piled on top of that – geopolitical crises, economic uncertainty, and fears about professional futures.
All of these factors can affect physical and mental health and aggravate complaints such as back pain. And this is something I see reflected in my patients as well.
What are the most common causes of back pain when no injury is involved?
These days, it is less often a matter of a single structural problem and more the interplay of various factors. Lack of movement, prolonged sitting, one-sided strain, and an overall insufficient level of physical activity frequently cause muscles and the musculoskeletal system to lose their resilience.
Another important factor is stress. Persistent professional or personal pressure can lead to increased muscle tension, and pain can be intensified or become chronic. Poor sleep, insufficient recovery, and psychological burdens also play a decisive role.
Prolonged stress leads to increased release of the stress hormones cortisol and adrenaline. This heightens pain sensitivity, can promote inflammatory responses, and reduces the body's capacity to recover.
On top of this come individual factors such as excess weight, low physical fitness, and fear of movement. This so-called fear of movement can cause those affected to avoid physical activity altogether, leading to further muscle deterioration and creating a vicious cycle of pain, rest, and increasing limitation.
Do pain symptoms – particularly back pain caused or intensified by stress or anxiety – present differently from pain that arose purely from an injury?
Yes, differences often become apparent even during the case history and clinical examination. When there are clearly structural causes, the patient's history and clinical examination usually reveal distinct patterns. Certain movements, pain behavior, or the patient's compensatory mechanisms can often be traced back to a specific structure.
With psychosomatically influenced back pain, by contrast, there is often no clear clinical picture. The complaints are frequently variable, pain intensity can fluctuate considerably, and the symptoms cannot always be explained by any structural finding.
Beyond that, complaints tend to worsen during stressful situations or when anxiety and worry are present, and ease during periods of rest and relaxation – on vacation, for example. Also typical are a long history of suffering and persistently elevated muscle tension, particularly in the neck, shoulder, and back.
Do these complaints also differ in terms of where and how intensely the pain occurs, or how long it lasts?
Often no clearly defined pain location can be identified. Instead, the affected area is frequently widespread and diffuse. Pain intensity often fluctuates considerably on the visual analogue scale (VAS, 0–10) without any clear physical triggers being apparent. Another characteristic is that a consistently positive course of treatment is rarely seen.
How does treatment change when psychosocial factors are involved?
One very important building block is "Explain Pain". Patients often lack clear, understandable information about how their pain develops, as well as targeted pain management strategies. It is therefore essential to listen carefully and to work together with the patient to identify possible triggers and individual contextual factors, explaining them in an accessible way.
It is equally important to foster body awareness and to meet patients where they currently are. Through active, individually tailored therapy, patients can experience firsthand what their body is capable of despite the pain. The focus should be on making existing resources and abilities visible, rather than dwelling on limitations. This builds trust in one's own body, reduces fear of movement, and promotes long-term self-efficacy.
Can you illustrate with a concrete example just how strongly emotional burdens can influence back pain?
I once had a patient named Horst who every night, around 3 a.m., could no longer stay in bed. Because of his severe back pain, he would get up and spend the rest of the night sleeping in an armchair in the living room.
Horst and I went through all his movements together, reviewed an MRI scan – which naturally showed age-appropriate changes at his stage of life – and analyzed his sleep patterns, even checking his mattress. Despite all of this, his symptoms did not improve.
It was only when Horst told me that his wife had suddenly left him exactly one year earlier – on his 70th birthday – that a possible connection became clear. He himself had not initially been aware of it. Horst simply could no longer sleep in the marital bed they had shared.
Once he recognized this connection, he decided to make some changes. Horst bought a new bed, redecorated parts of his home, and gradually came to terms with the loss. Combined with therapy, this had a clearly positive effect on his symptoms. Today he is able to sleep through the whole night in his bed again.
Where do you draw the line as a physiotherapist – and when is a doctor or psychotherapist needed?
As physiotherapists, we must engage in clinical reasoning at all times – listening carefully, analyzing, critically questioning our hypotheses and treatment approaches, and identifying the underlying cause of the complaints.
It is important to help patients recognize possible connections and to develop strategies together for managing their symptoms.
When it becomes clear that the problem reaches deeper into psychological or psychosomatic territory, a referral or ongoing treatment by an appropriate specialist or psychotherapist should be recommended in consultation with the referring physician.
It is important to communicate this openly to the patient while also recognizing the limits of one's own professional role.
How can stress, anxiety, and emotional burdens affect the healing process?
Stress, anxiety, and emotional burdens can significantly influence both the course of treatment and the healing process.
Prolonged stress leads to increased release of stress hormones such as cortisol and adrenaline. This raises muscle tension, can heighten pain sensitivity, and impairs tissue recovery.
Anxieties and worries can lead patients to avoid certain movements or to reduce their activity levels altogether (fear-avoidance behavior). This promotes muscle loss, loss of strength, and reduced resilience – meaning complaints often persist or may even worsen.
With chronic back pain, the term "pain memory" often comes up. What actually happens in the body during this process?
Pain memory plays a central role in chronic back pain. When pain persists over a prolonged period, the nervous system can become more sensitive. Pain signals are processed more quickly and intensely, so that pain can continue even when the original cause has already healed or no longer provides a sufficient structural explanation. This is referred to as sensitization of the nervous system.
In chronic pain, neuroplasticity is of crucial importance: pain pathways can be "trained" by persistent pain and thereby become more sensitive – a process known as central sensitization. The brain "learns" the pain, and a pain memory develops. As a result, pain can persist even though the original tissue has already healed.
As someone affected, what can I do to break out of the pain cycle?
Quite a lot. The most important thing is to stay physically active and not avoid movements out of fear of pain. An individually tailored strength and movement training program helps rebuild resilience and restore trust in one's own body.
Back pain can persist even when the original cause no longer fully explains the symptoms. Physiotherapist Nils Stützer explains what stress and anxiety have to do with it – and how to break the pain cycle
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An interview with
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