Chronic Low Back Pain, Beyond Injections: Insights from Harvard Rounds
I recently attended the virtual Harvard Interdisciplinary Pain & Headache Rounds lecture on chronic low back pain.
The data and recommendations shared align closely with how I believe we should be treating chronic pain: by de-emphasizing routine spine injections, taking the brain’s role seriously, and prioritizing education, physical rehabilitation, and relationship-centered, nervous-system-informed care for people living with persistent pain.
What follows is an outline of the key points and how they inform a practical care pathway (useful for both practitioners and patients seeking informed care.
1. Chronic pain is NOT just “the same injury/pain, just lasting longer.”
Many treatment patterns for chronic low back pain were borrowed from acute care. In the acute phase, targeted procedures can be helpful; in persistent pain, the physiology changes. Over time, pain processing increasingly involves learning, attention, mood, threat appraisal, and other central mechanisms. That does not make pain “less real.” It clarifies why single-site, one-time fixes often underperform once pain is chronic.
Key points:
A pain generator might start in the body (a disc, a joint, an injury).
But as pain becomes chronic, the brain takes over.
Activity shifts into emotional and associative areas; the system gets better at “doing pain,” even when the original tissue damage has calmed down.
Imaging can mislead us—we see “something” on MRI and assume that must be the villain, even when that same “something” shows up in people with no pain.
If you’ve had back pain for months or years, your experience is absolutely real—but it’s no longer as simple as “my back is broken.” It’s your nervous system, your learning history, your stress load, your sleep, your beliefs, your support, all braided together.
When we ignore that and keep hunting for the one perfect spot to inject, burn, or fuse, we end up chasing ghosts.
2. Routine injections, all too common, often fall short (and disempower healing).
The lecture walked through this historical arc:
Anesthesia + early injections changed medicine. Suddenly we could block pain.
Over time, injections and procedures became central to pain clinics.
Eventually, they also became some of the most lucrative parts of pain practice.
And slowly, a tool meant for acute and clearly targeted pain slid into being marketed as the answer for chronic spine pain.
Fast forward to now:
Recent BMJ guidance and meta-analyses strongly recommend against many commonly used spine injections for people with chronic axial or radicular back pain lasting more than 3 months.
Not “never ever use in any context.” But, we urgently need a major rethink of routine injections as the go-to for chronic low back pain.
Here’s why that matters to me:
When we keep telling (or insinuating to) patients, “This next injection might finally fix it,” we:
Keep them dependent on the system.
Reinforce the idea that nothing they do matters unless a needle or machine is involved.
Delay the care that actually helps rewire a sensitized nervous system.
This is the opposite of empowerment.
3. Language matters: it can empower or incapacitate.
Well-intentioned explanations can unintentionally reinforce fragility: “Your back is damaged,” “You have the spine of an 80-year-old,” or “Only this procedure will fix it.” The lecture emphasized providing accurate, calming, and actionable education.
People do better when they understand that:
Pain is modifiable, even when chronic.
Imaging findings are common and often incidental.
Gradual exposure to movement is safe and beneficial.
Many small inputs (sleep, stress load, activity, beliefs) influence pain intensity.
Clinical implication: use language that builds capacity and clarifies next steps rather than closing doors.
4. What type of pain management actually helps chronic pain?
For people living with chronic low back pain, our priorities should be:
Eliminate and treat anything truly treatable.
Rule out red flags. Address what’s clearly fixable. Don’t ignore obvious structural or systemic issues.Provide a real diagnosis.
Not just “your MRI is a mess; good luck.” People need context:“Here’s what’s going on.”
“Here’s what it means.”
“Here’s what it doesn’t mean.”
A grounded explanation calms fear—fear is gasoline on the pain fire.
Offer an ongoing relationship, not a one-off procedure.
This can look like:Health coaches
Nurses
Behavioral medicine + pain psychology
Education
Encouragement
Practical tools and check-ins
Chronic pain is a long-term conversation, not a single visit.
Encourage self-management.
Not as code for “you’re on your own,” but:“Here is what you can do each day that actually moves the needle.”
“Here’s how we support you while you do it.
This model respects the complexity of chronic pain and still hands the patient their power back.
Another message I appreciated: a lot of things help a bit—and that’s not a failure.
Options like:
Exercise and graded movement
Heat
Yoga, Tai Chi
Massage
Acupuncture
Cognitive and behavioral approaches
Lifestyle changes (sleep, stress, smoking, alcohol, food, pacing)
Individually, many have modest evidence. But:
Chronic pain is person-specific.
Small wins layered consistently can re-train a sensitized system far more honestly than chasing one dramatic “cure.”
For my own work and for our patients, the takeaway is: Less “miracle fix.” More custom toolkit, built around nervous system regulation, movement, meaning, and support on an individual basis.
The things I’ll be echoing until my patients and clients are tired of hearing it (and will probably continue to echo anyway):
Use injections wisely, not reflexively. Great for some acute scenarios and select cases; not a personality trait of your treatment plan.
Use the right language; empower, don’t incapacitate. When we say, “This one procedure/treatment will finally fix your broken back,” and it doesn’t, we reinforce helplessness. I never want our patients to feel like a failed experiment.
Treat chronic pain as a brain–body learning condition. Not “it’s in your head” as dismissal—“it’s in your nervous system” as validation and an opening. If the system learned pain, it can also learn safety.
Prevention and early empowerment matter. How we talk about pain from day one shapes whether it quiets down or spirals into something long-term.