I now don’t identify with having chronic low back pain, but I did!
We’re delighted to share Graham Curlewis’s story on our blog this month. Graham is a physiotherapist who himself experienced debilitating chronic back pain in his early career. Later, through the lens of his education in modern pain science, Graham was able to make sense of his symptoms and shares his insights in this blog. Today, Graham draws upon his lived experience of recovery and professional training in mind-body medicine to help others within his clinical work.
My experience with chronic pain: how it all began
I don’t usually think of myself as someone who’s had chronic pain. But when I really think about it… I have! It all feels like such a long time ago, and I’ve been pain‑free for about 20 years now, so it rarely crosses my mind. Looking back though, it was genuinely disabling.
In my mid‑20s I was plagued by recurring low back pain. I remember working as a young physiotherapist on the orthopaedic ward in 1992, lifting a patient with a nurse. The call was, “on three - one, two, three…” - and then, ow‑yah! I felt a pop in my back as I lifted, and the nurse didn’t. That moment marked the start of a long journey of “looking after” and protecting my back that lasted at least 10 years.
How I initially understood my pain
At the time, I was convinced I’d “popped” a disc. I remember being driven from Stirling back to Edinburgh lying in the back seat of the car because sitting was just impossible due to the severe pain. I was probably off work for a week or two. I don’t remember feeling stressed as such, but I would have been a young physio, still wet behind the ears and not fully comfortable in my own skin. I didn’t enjoy orthopaedic ward work either. What I do remember clearly was the pain - and how much I feared it. The spasms, the inability to straighten up… I can really remember that now that I focus on it!
Throughout the 90s, I was a conscientious patient using all my physio knowledge to treat myself. I did my fashionable ‘McKenzie’ stretches (basically the cobra position in yoga), with the strong belief that I was "pushing the disc back in"! I used loads of lumbar rolls – the little cushioned rolls you put at your lower back. I was an expert through lived experience on which ones were good, and which were rubbish. I was able to recommend the good ones to my patients, who I could empathise with.
Things would settle for a while, then flare up again. I remember one Hogmanay lying on the floor watching the fireworks from Edinburgh Castle on TV because I couldn’t stand for long. Going to a party - never mind the Street Party - felt simply unachievable. I had X‑rays, lots of well‑meaning peer support in the form of mobilisations, and time on the traction unit in the hospital where I worked. It didn’t disable me all the time, but it did destroy my confidence in my back during that period.
A pain spiral
In 2001, I went to Australia to study for a year. One of my lecturers was Max Zusman, a world authority on pain who was well ahead of his time. The pain lectures were heavy on brain anatomy and neurochemistry, complicated and very intense. Max expected very high standards from all of us and we all wanted to perform for him. I had five exams over 5 days starting in three days’ time, and “Pain Theory” was the first. I’d been studying hard and knew my stuff, but I felt enormous pressure to understand everything like a neuroscientist.
After sitting at my desk all day studying, I decided a run along Cottesloe Beach in Perth would clear my head. A beautiful place, great idea! Or so I thought. About five minutes into my jog, my back completely seized. I shuffled home rigid with tension, and as my anxiety rose, the pain spiralled. By that night I was in agony, barely slept, and could hardly get out of bed the next day. I ended up needing a GP call-out and morphine injection - all from a 5-minute jog?! I couldn’t believe the timing and how my back had chosen this moment to flare up! I remember being in a panic. Feeling scared, frustrated, confused and preoccupied by the pain.
Struggling on… and then a surprise
On the day of my pain theory exam, I couldn’t sit, so I did the 90-minute paper lying on the floor in my “safe” McKenzie cobra position. I still remember Max shaking his head in disappointment, and my peer’s friendly but not‑so‑sympathetic mockery. They thought it was hilarious. I did not.
And then - almost unbelievably - the pain settled. I completed the next four exams, was able to sit in a chair, went to the end‑of‑year ball, and danced like a complete loon with no consequences at all.
Making sense of this surprise
I went on to have episodes of low back pain after that, but never anything like that one. It was the most severe pain I’ve ever experienced. Looking back now, I can see how unready I felt for that exam, despite passing well (on no sleep and in a lot of pain). I can understand it now as my nervous system shouting, “Stop! Where are you going? Get back and study more!” My brain was trying protect me and the symptoms were that protective output. But as soon as I felt that familiar pain, fear kicked in - and I was straight into a vicious cycle and now the pain was my central focus, biggest threat and concern. Maybe my brain didn’t want me to do the exam for fear of failure, who knows! The point is there is no way I had damaged my back.
I don’t really remember a moment of “healing”. It just… happened. Over time, evidence changed, I learned to stop bracing my core, to relax, and to trust that this was safe. I learned that bending my back wasn’t dangerous and that I didn’t need to perch rigidly on a chair or sit with a lumbar roll (which was so liberating!). The protective habits I’d spent a decade perfecting (and teaching!) weren’t helping me. In fact, for me (and in hindsight, more generally), they were part of the problem. I think once I could see an improvement and learned to trust my back again through relaxing, letting go and not fearing the pain, it got better gradually.
Finding SIRPA – and the missing piece
It wasn’t until 2017, when I attended the SIRPA (Stress Illness Recovery Practitioners’ Association) conference focusing on emotions in chronic pain that I truly understood that period of pain and the role anxiety and fear played in it. I’d been very “bio” focused and hadn’t truly grasped the psychosocial, let alone the psychophysiological drivers of that severe episode. Even understanding the possibility of creating a centrally sensitised state in my brain through top-down upregulation couldn’t take me away from the belief that there had to have been some damage in my back.
I can see now that none of my pain throughout that time period was linked to any damage. My personal threat-load was massive at the end of my year in Australia. I had a sense of urgency to know and understand more as I was being tested in the end-of-year exams. This was a real threat to my psyche, but not my physical body. I hadn’t damaged anything, but my brain was in full panic mode and desperately trying to communicate this to me. There was huge conflict in me – a part of me saying ‘This is too difficult, you don’t know this stuff well enough. You may as well give up!’ and another part of me saying ‘You need to do this. You didn’t do all this work to fail now! You can’t fail this course!’ When I now look at pain as a threat alarm, all of this makes sense. I had reached a point before my run where my threat was very high. I knew this, I could feel the anxiety. But the real threat then became the belief I had damaged my back.
The protective output from my brain was being ramped up in an attempt to protect me. First the anxiety in the build-up to the exams. Then the pain sensations in my back. Then the muscle guarding. Then through heightened fear and avoidance and beliefs of damage, more pain.
As my sense of threat increased, my brain simply did what it had learned to do: protect me through making me more sensitive in my vulnerable area and tensing for protection. Once my attention switched to my back and my catastrophic thoughts kicked in, the vicious cycle was complete.
Life after recovery
I have recovered from chronic back pain. It's a distant memory now and doesn't feature in my life at all. I've since returned to martial arts, done triathlons and kept up my general fitness without giving my back a second thought.
Recovery from chronic back pain is absolutely possible and should be celebrated as the norm, not the exception.
The impact of my experience on my clinical practice
I now treat chronic pain from a mindbody perspective and combine my years of training in manual therapy, exercise therapy and cognitive functional therapy (CFT) with Pain Reprocessing Therapy (PRT) and the SIRPA approach more generally. I love this work. It has really allowed me to understand the bigger picture of what's going on with people. I no longer struggle to make sense of why someone has a random setback for no apparent physical reason.
This has been hugely unburdening for me as a clinician. Before, I think I was desperately looking for that tight joint in the lower back, or the muscle that was either overactive or weak, that needed to be identified by me and then fixed by me.
Now I understand that it's really about looking at how safe a person feels in every aspect of their life. The more threat there is across different areas, the more protective outputs the brain produces. Just understanding this has really helped me see how and why people move and behave differently.
Of course, it's not always easy. This is a concept rooted in modern neuroscience. It's cutting-edge, if you like. So, I often feel like I'm swimming against the tide, working against the barrage of biomedically inaccurate information coming from social media, the mainstream media, and even well-meaning colleagues and doctors.
But it's encouraging to see the change over time. More and more, people and healthcare providers are being exposed to these concepts and beginning to accept them. They almost have to, because the evidence is building all the time.
My work today
I still work as a regular musculoskeletal physio, seeing the usual conditions: back pain, neck pain, tendinopathies and so on. Although integrating the mind-body approach can be harder work, it's much more enjoyable. I have to remember to meet people where they are. Not everyone is ready for this approach.
For some people, it can be very challenging even to contemplate that the drivers of their discomfort might be coming from the brain rather than being a marker of the state of their tissues. Many people want "the stretch" or a specific "physio exercise" that will cure their problem, and there are lots of fashionable exercises to choose from. But often people are very open to a different explanation, especially if they've been through treatments and investigations without success.
I'm also seeing more and more patients who already know about neuroplastic symptoms and either want a full assessment to help confirm whether that's what they're experiencing or are feeling stuck in their recovery and looking for coaching and rehabilitation.
The sources of threat in individuals is potentially endless and figuring out where the threat lies can feel quite daunting for people. At the moment, there is no agreed structure for how this approach should be delivered. I've found the work of Peter O’Sullivan (CFT), Alan Gordon (PRT), Howard Schubiner (Emotional Awareness and Eexpression Therapy) and Georgie Oldfield (at SIRPA) to have been most influential on me and have integrated their teaching into my own framework: The Five Pillars of Safety.
There is no going back for me now. I can't unsee what now seems obvious. I strongly believe this understanding will continue to revolutionise healthcare. It may take decades, but the momentum seems to be building quickly.
I'm glad to be in this space relatively early. Through SIRPA, the Association for the Treatment of Neuroplastic Symptoms (ATNS) and Living Proof, I've met some wonderful people who really get this work but also understand the struggle of trying to teach these ideas to a society that has relied on an outdated model for explaining symptoms.
For me, embracing the neuroscience and mindbody approach is definitely the only way forward.
