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Inspiration: Episode 29: Running on 18% of the Mind Your Body podcast with Dr. Nevo.

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TL;DR: When chronic pain gets dramatically worse but imaging stays the same, the structure usually is not the story. Cumulative stress, a depleted nervous system, and a narrowed window of tolerance are often driving the collapse. Understanding this reframe is the first step toward rebuilding capacity, not just managing symptoms.

If you take nothing else from this article:

• Worsening pain does not automatically mean worsening tissue damage.

• Allostatic load, the total stress your body has carried across a lifetime, can shrink your capacity to cope until the system tips over.

• Central sensitization causes the nervous system to amplify pain signals even when peripheral tissue is unchanged.

• Sensory processing sensitivity (HSP trait) affects roughly 15 to 20 percent of people and narrows the window of tolerance.

• Rebuilding starts with regulation, safety, and honest energy accounting, not pushing harder.

Picture a grocery store. Lights too bright. Sounds too loud. The whole aisle moving through fog. You used to love shopping. Now you can barely make it to the register.

That is where Emma was when she came to see me. Twenty-six years old. Seventeen years of pain. Ten specialists. Stacks of imaging.

And a question none of them had answered.

Why now?

The Question Behind the Question

Emma had lived with back pain, joint pain, and hypermobility since childhood. Doctors kept telling her she was too young for this. I never say that to a patient. Pain can happen at any age.

Her recent decline was something different. Brain fog thick enough to lose words mid-sentence. Episodes where she felt like she was crawling out of her skin. Moments at the mirror where she did not feel like she was really there.

Her mom sat beside her and said something I keep thinking about. Every night she has a little breakdown. She just wants to go back to a year ago when things were better.

A year ago, Emma had pain too. She had it seventeen years running.

So the structural story did not explain the collapse. Something else did.

The Reactivity Changed, Not the Symptoms

I told Emma what I want you to sit with today. Her symptoms had not gotten dramatically worse. Her capacity to carry them had gotten smaller, and her nervous system had gotten louder.

People hear that and worry I am saying the pain is imaginary. The pain is completely real. What changed was the volume knob, not the invention of the sound. Research on central sensitization confirms this: the nervous system can amplify pain signals even when peripheral tissue is unchanged [1].

To explain the volume knob, I use a concept called allostatic load.

Key Point: Chronic pain can worsen without any new structural damage. A depleted nervous system amplifies signals the body was already producing.

The Bucket That Finally Overflowed

Allostatic load is the total stress your body has carried across your life. A hard week at work is part of it. So is everything going back to the womb, to what your parents carried, even to what your grandparents survived. That last part is real. It is called epigenetics, and stress responses can travel across generations.

Picture a bucket. You are born with some water already in it. Childhood adds more. Adult life adds jobs, relationships, surgeries, infections. The bucket has a limit.

Emma’s bucket had been filling for 26 years. Eighty hour weeks at a Big Four firm. An antibiotic reaction. A surgery. A roommate in psychiatric crisis. Two years without a period from stress.

Then it overflowed.

A 2024 prospective study using data from the National Survey of Midlife Development in the United States found that higher allostatic load was significantly associated with increased odds of high-interference chronic pain [2]. A 2023 study published in PAIN found that greater allostatic load correlated with thinner insula cortices, greater pain disability, and lower physical function [3]. A 2025 analysis in PAIN describes how allostatic load erodes resilience and helps pain take hold. Emma’s imaging stayed the same. Her reserves did not.

Key Point: Allostatic load builds silently across a lifetime. When the bucket overflows, pain does not just worsen. It becomes a different kind of problem entirely.

The Phone at 18 Percent

I used this analogy with Emma and she got it immediately.

Think about your phone. Start the day at 100 percent and you can scroll, call, and navigate all day. Start at 18 percent and it dies by noon. You have to charge it.

Nobody feels guilty charging a phone. Nobody calls filling a gas tank laziness. With our own energy, though, we expect to push through on empty and wonder why we keep crashing.

Emma was waking up at 18 percent and asking her body for a full day. The crash was not a character flaw. It was math.

Key Point: Energy accounting is clinical information. Knowing your real starting percentage changes how you plan the day.

High Functioning Freeze

Emma looked like she had it together. Job, apartment, independence. Underneath, she was running a survival response I recognize in high achievers who have been coping far longer than anyone knew.

A threatened animal fights, flees, or freezes. Freeze is the shutdown state, playing dead. Humans learned to freeze while still moving. They build a part that shows up, pays the bills, and smiles on cue while everything else runs on fumes.

Emma got through the workday, then collapsed at home. Weekends were not for rest. They were for recovering from the week so she could make it through the next one.

If your days off exist only to survive your days on, that is a data point worth taking seriously.

Key Point: High-functioning freeze is not wellness. It is a survival response wearing a productive face.

The Window of Tolerance

Imagine a zone where you can meet life without tipping over. Inside it, you handle stress, process emotion, and function. That is your window of tolerance.

Go above it and you land in fight, flight, or high functioning freeze. Everything feels too loud, too bright, too much. Drop below it and you get shutdown, dissociation, and that hollow sense of not being in your body.

Emma lived outside her window most of the time. Research on childhood trauma and nervous system dysregulation shows that early adversity can leave the nervous system stuck in chronic high-alert states, narrowing the window of tolerance and increasing vulnerability to pain and overwhelm [4]. Seventeen years of pain had primed hers to shrink.

The therapeutic goal is to widen the window, not eliminate stress. A wider window means you can carry more before tipping out of it.

Key Point: The window of tolerance is trainable. Early adversity narrows it, but regulation practices can gradually expand it.

Inside the Visit

What Happened Before I Touched Her

Before I ordered anything, I acknowledged what Emma had been through. When you have seen nine doctors and no one has connected the dots, you start to wonder if you are the problem. I told her I could not imagine the full weight of it. Her shoulders dropped an inch.

Then Emma said something that told me she already understood more than she realized. She said the acupuncture and her medication made her nervous system feel less reactive. She used that phrase herself. Nervous system.

So I followed her lead. I explained that chronic pain changes how the brain processes signals, and that a dysregulated nervous system amplifies everything. I introduced allostatic load and the highly sensitive person concept.

Highly Sensitive, Not Malfunctioning

Roughly 15 to 20 percent of people have sensory processing sensitivity (SPS), a trait first identified and validated by psychologist Elaine Aron [5]. It is a trait, not a diagnosis. People with SPS process sensory and emotional input more deeply. They feel the emotional temperature in a room. They notice what others miss. Neuroimaging research confirms that HSPs show heightened brain activation in regions tied to awareness and empathy [6].

That depth is a real strength. It also means pain and stress land harder, and the window of tolerance tends to sit narrower.

Emma nodded when I described it. She was wired to process more, and no one had ever helped her build the regulation to match that wiring.

Key Point: Sensory processing sensitivity is a biological trait, not a flaw. The clinical task is building regulation capacity that fits how the nervous system actually works.

What to Do With the Anger

Her mom mentioned that Emma said the same words every night. It is not fair.

I looked at Emma and told her the truth. When your boundaries feel crossed and your life feels stolen, anger is the appropriate response. The question is where it goes.

Anger with nowhere to go settles into the body as tension and guarding. Emma needed permission to feel it out loud, and she needed a container for it.

You have that permission too. Whatever you feel about your pain and your changed life is valid.

Key Point: Unfelt anger does not disappear. It relocates. Giving it a container, like a journal, is part of the clinical work.

Both Things Are True

I want to be precise here. Emma had real structural findings. Hypermobility. A disc bulge at L5 to S1. A reverse curve in her neck that usually reflects chronic muscle guarding. Possible craniocervical instability.

Those findings matter for how we plan treatment and rehab. And her nervous system stuck in survival mode was driving the disability that kept her out of the grocery store.

I hold both of those realities at once. A sensitized nervous system and real structural findings can live in the same body, each shaping the other. This is the both-and approach to pain, and it is the only framework honest enough to account for what Emma was actually living.

The clinical work is deciding which findings carry meaning for this person, right now.

Key Point: Tissue findings and nervous system dysregulation are not competing explanations. They coexist, and treatment has to account for both.

Surgery Counts as Stress

Emma had a necessary surgery in September, and afterward everything worsened. The operation likely fixed what it was meant to fix. It also delivered a major stressor to her body. Anesthesia, incision, recovery, all of it lands on the nervous system.

When the bucket is already near the rim, a surgery can be the thing that tips it. This is not an argument against needed procedures. It is a call to treat the nervous system as part of recovery, not an afterthought.

Key Point: Every medical event is also a nervous system event. Recovery planning should account for both the structural repair and the stress it delivers to the body.

What We Actually Did

Emma did not leave without pain. She left with a map.

1. Validation. Her experience was real and it made sense.

2. A reframe. Her body was not disintegrating. Her nervous system was stuck in survival mode and her reserves were depleted.

3. Assessment. A HeartMath reading of her heart rate variability to see her baseline. HRV biofeedback has demonstrated meaningful clinical benefits across chronic pain conditions, including reductions in pain intensity, depression scores, and anti-inflammatory medication use [7]. A systematic review in Applied Psychophysiology and Biofeedback further confirmed significant positive effects on pain, autonomic function, and quality of life [8].

4. Safety first. Safe and Sound Protocol and gentle manual therapy to teach her nervous system what safety feels like before any desensitization work.

5. A team. Coordination with her physical therapist, occupational therapist, and acupuncturist. Healing happens in community, not in isolation.

Three Practices You Can Start This Week

Pick one. Consistency over the next two weeks matters more than doing all three once.

1. The battery check in. Each morning, ask what percentage you are actually at. Not what you wish. If you are at 40, do not plan a 100 day. Adjust honestly.

2. The interoception timer. Set three alarms a day. When one sounds, scan your body. Energy, pain, emotion. Change nothing. Just notice. Catching overwhelm early beats catching it at zero.

3. The anger journal. Each night, write down one thing you are angry about. Let yourself feel it. You do not have to solve it. Anger you name stops living silently in your muscles.

The Science of Safety

Your nervous system has one job. Keep you alive. It cannot always tell a real threat from a perceived one. A tiger and an overflowing inbox can trigger the same alarm.

Live in chronic stress long enough and the system concludes the world is dangerous. In that state, pain thresholds drop and everything hurts more. Research confirms that persistent physiological stress dysregulation, the biological definition of allostatic overload, is associated with measurable changes in brain structures involved in pain processing [3].

The way out is to give your nervous system repeated experiences of safety until it believes them. That is what gentle manual therapy does. That is what coherence training does. That is what a provider who actually listens does.

Key Point: Safety is not a feeling you talk yourself into. It is a state the nervous system learns through repeated physical and relational experience.

Where Emma Goes From Here

Emma will not return to who she was before the pain. None of us can unknow what we have lived. She can move forward and build a life that feels connected and alive, with the tools to widen her window a little at a time.

If this resonates, hold onto three things. Worsening pain does not automatically mean worsening tissue. Your starting percentage each day is real information, not an excuse. Small, consistent steps rebuild capacity in ways that pushing through never can.

Your nervous system has been protecting you a little too hard for a little too long. It learned to do that. It can learn something else.

I am Dr. Zev Nevo. Your pain is real. Your story matters. And rebuilding is possible.

Frequently Asked Questions

Why does chronic pain get worse when imaging looks the same?

Imaging shows structure. It does not show the state of the nervous system. Central sensitization means the brain and spinal cord can amplify pain signals even when peripheral tissue has not changed [1]. Reduced coping capacity, driven by allostatic load, can make existing signals feel louder and more disabling [2].

What is allostatic load and how does it affect pain?

Allostatic load is the cumulative biological cost of chronic stress across a lifetime. When it exceeds the body’s adaptive capacity, physiological dysregulation follows. Higher allostatic load is associated with greater pain disability, thinner brain cortices involved in pain regulation, and lower physical function [3].

What is the window of tolerance and why does it matter for chronic pain?

The window of tolerance is the zone of nervous system activation where a person can function, process stress, and regulate emotions. Outside that window, pain signals amplify and everyday demands become overwhelming. Childhood adversity and prolonged pain narrow the window. Regulation practices can widen it over time [4].

What does it mean to be a highly sensitive person in the context of chronic pain?

Sensory processing sensitivity (SPS) is an innate biological trait in roughly 15 to 20 percent of people [5]. HSPs process sensory and emotional input more deeply, which means pain and stress tend to land harder. The window of tolerance tends to sit narrower. Building regulation capacity that matches the nervous system’s actual wiring is the goal, not suppressing sensitivity.

Can surgery make chronic pain worse even if the procedure was successful?

Yes. Surgery is a significant biological stressor, regardless of its outcome. Anesthesia, incision, and recovery all place demand on a nervous system that may already be near capacity. When allostatic load is high before the procedure, a necessary surgery can still tip the bucket. This is why nervous system preparation and post-operative regulation support matter.

What is HRV biofeedback and does it help with chronic pain?

Heart rate variability (HRV) biofeedback is a non-pharmacological intervention that trains coherence between heart rhythm, breathing, and nervous system regulation. A systematic review found clinically meaningful reductions in pain intensity, depression scores, and medication use [7]. A broader review confirmed positive effects on autonomic function, sleep, and quality of life across chronic conditions [8].

What is the difference between managing pain and rebuilding capacity?

Managing pain targets symptom reduction. Rebuilding capacity targets the nervous system’s ability to handle stress without tipping into dysregulation. The goal is a wider window of tolerance, better energy accounting, and the ability to live fully rather than just survive each day.

Where do I start if I recognize myself in this article?

Start with one thing: the battery check-in. Each morning, honestly assess your actual energy level. Do not plan a 100 percent day on a 40 percent charge. That single habit builds interoceptive awareness and begins the shift from pushing through to working with your nervous system.

Key Takeaways

• Chronic pain that worsens without structural change is usually a nervous system and capacity problem, not a tissue problem.

• Allostatic load accumulates across a lifetime and can tip the body into a state where pain becomes amplifying and disabling, even when imaging is unchanged.

• Central sensitization allows the nervous system to produce more pain from the same input. Understanding this reframes the experience from physical decline to neurological dysregulation.

• The window of tolerance narrows under chronic stress and early adversity. Widening it through safety-based practices is the therapeutic target.

• Sensory processing sensitivity affects roughly 15 to 20 percent of people. For those with this trait, pain and overwhelm land harder, and regulation tools need to be calibrated accordingly.

• Every medical procedure, including successful ones, is a nervous system event. Recovery planning should include nervous system support, not just structural repair.

• Rebuilding starts small: honest energy accounting, body awareness, and safe emotional expression. Consistency over weeks matters more than intensity on any single day.

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About the Author:
Dr. Zev Nevo is a double board-certified physiatrist, chronic pain survivor, and founder of the Body & Mind Pain Center. He helps people with persistent pain rebuild capacity and confidence using an evidence-based, trauma-informed mind-body rehabilitation approach.

Listen: Mind Your Body Podcast

Learn & Join: Mind-Body Rehabilitation Community

Visit the Clinic: Body & Mind Pain Center

Medical Disclaimer:
The information in this article is for educational and informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified healthcare provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read in this article. New or changing pain symptoms should always be properly evaluated by a medical professional.

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References

[1] Latremoliere A, Woolf CJ. Central Sensitization: A Generator of Pain Hypersensitivity by Central Neural Plasticity. Journal of Pain. 2009;10(9):895-926.

[2] Liang Y, Booker C. Allostatic load and chronic pain: a prospective finding from the national survey of midlife development in the United States, 2004-2014. BMC Public Health. 2024;24(1):416.

[3] Farris SG, Thomas JG, Haas-Howard C, et al. Elucidating individual differences in chronic pain and whole person health with allostatic load biomarkers. PAIN. 2023;164(12):2829-2839.

[4] Volcheck MM, Graham SM, Fleming KC, Mohabbat AB, Luedtke CA. Central sensitization, chronic pain, and other symptoms: Better understanding, better management. Cleveland Clinic Journal of Medicine. 2023;90(4):245-254.

[5] Aron EN, Aron A. Sensory-processing sensitivity and its relation to introversion and emotionality. Journal of Personality and Social Psychology. 1997;73(2):345-368.

[6] Acevedo BP, Aron EN, Aron A, Sangster MD, Collins N, Brown LL. The highly sensitive brain: an fMRI study of sensory processing sensitivity and response to others’ emotions. Brain and Behavior. 2014;4(4):580-594.

[7] Kiberd M, Clarke S. Effectiveness of non-invasive vagus nerve stimulation vs heart rate variability biofeedback interventions for chronic pain conditions: A systematic review. Pain Practice. 2025;25(1):e13291.

[8] Goessl VC, Curtiss JE, Hofmann SG. Heart rate variability biofeedback in chronic disease management: A systematic review. Applied Psychophysiology and Biofeedback. 2021;46(3):195-206.