34 Surprising Causes of Pain

There are many paths to pain that never make headlines.

Trying to understand pain when there is no obvious explanation

In healthcare, we’re always trying to help people with problems we don’t fully understand, using treatments we don’t full understand. The world is full of unexplained pain particularly, with many dozens of possible causes. By far the most important thing to understand about treating chronic pain is that it is difficult because it almost never has one cause: it is extremely multifactorial. It’s always a game of Whac-A-Mole with chronic pain — but with some really strange moles. And well-camouflaged moles.

I publish a busy website about pain, and so I get email like this more often than I change my socks:

I’ve been to every medical specialist you can imagine. They can’t find anything wrong with me. The psychiatrist says it’s not in my head, and the rheumatologist says it’s not in my body. But something is causing my pain. It’s not an infection or a fracture or a cancer. It’s not a sprain or a pinched nerve or a cattle prod. What else is there? What else is left?

What else indeed? When “obvious” and known causes of pain have been eliminated, what next? What else causes pain? How else can pain start, change, worsen? This article summarizes 34 of the not-so-obvious ways to hurt, the things that might help you understand pain that has defied diagnosis or explanation so far. There are a lot more possibilities, but it’s a start, and this article hopefully focusses on the most important.

A lot of pain is unexplained

A man hid a little wad of marijuana up his nose, and then lost it up there and then forgot it for almost twenty years — oops! — until it started causing severe headaches:

Through the years he suffered recurring sinus infections and had trouble breathing out of the right side of his nose. But he didn’t connect the problems to his lost cannabis. It wasn’t until 18 years later — when he was struggling with headaches and had a CT scan of his brain — that doctors finally discovered the petrified pot.

Doesn’t get much more surprising than that! There are countless other less bizarre possibilities. The “official” causes of all kinds of chronic pain break down into three roughly equally large categories, plus one small “other” category:1

• injury (38%)
• unknown (31%)
• musculoskeletal (24%), a vague category dominated by arthritis, the rheumatic diseases, and headaches
• other (7%), which is mostly cancer and abdominal pain plus “everything else” (mostly pain related to major physiological systems, and one-in-a-zillion cases like petrified pot up your nose)

Misdiagnosis is routine, of course. Arthritis and the rheumatic diseases should probably be in their own major category, and almost everything else filed under “unknown. ” Pain after injury is surprisingly murky: sure, it might have started with an injury, but two years later is that still the “cause”? It has usually transmogrified into something else, and exactly how that works is much more about the “unknown” than “injury.” Many cases of chronic pain are hard to put in just one of these categories (or they only seem easy to place). As you browse around this article, you’ll notice that most causes of pain are hard to categorize.

Hypochondriac nightmare fuel

😱

A lot of the examples in this article are high-grade hypochondriac nightmare fuel, and it’s always risky to share information like that: stories about horrifying, insidious causes of pain can truly freak patients out (with a nocebo, the opposite of a placebo2), but most of them have pain that is not this ominous and will pass soon enough.

But such stories are also useful data points about the extreme diversity of hard-to-diagnose causes of chronic pain — an underestimated diagnostic challenge that needs more light. Both pros and patients need to have greater respect for that challenge because there are so many individually rare possibilities that they are collectively common. The chances of having any one weird cause of pain are extremely low, but the chances of having some pathological curve ball… not so rare!

Table of Contents

Basic mechanisms, processes, and concepts (potentially relevant to many injuries or illnesses, and a lot of these overlap partially or even completely):

And some specific pathologies (things that can be diagnosed, and in some cases treated)…

If I included every disease that causes aches and pains, this list would wrap around the Earth. I’ve narrowed it down to problems that are particularly notorious for both (a) evading diagnosis and (b) causing primarily aches and pains and other vague, non-specific symptoms (and not other symptoms that would easily lead to a diagnosis). Some of them are in a grey zone, of course.

Some more topics I’m considering for future updates to this article:

• multiple level radiculopathy (similar in spirit to subtle/intermittent myelopathy)
• painful anatomical oddities like os trignum syndrome (and there are quite a few of these actually)
• Whipple’s disease can cause a bunch of joint pain (interesting but super rare)
• fluoroquinolone toxicity
• the acne drug Isotretinoin (Accutane) may cause joint pain and, in rare cases, symptoms that mimic rheumatoid arthritis and axial spondyloarthritis
• mycotoxin poisoning from mold
• chronic low-grade infections, probably a bigger deal than we realize (and also overlaps with some crankery)
• autonomic neuropathy
• exertional rhabdomyolysis (much more common in the era of CrossFit), and weirdly it’s possible that “deep tissue” massage is also causing a lot of rhabdo
• inequality/injustice/poverty, the great predictors of chronic stress in humans, are strong causes of disease and all-cause mortality — which inevitably includes chronic pain — and this relationship remains strong even in places where access to health care is more egalitarian

Sensitization

Pain itself often modifies the way the central nervous system processes pain, so that a patient actually becomes more sensitive and gets more pain with less provocation. This is called “central sensitization.” (And there’s peripheral sensitization too.) Sensitized patients are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people. This phenomenon is usually superimposed over other problems, but it can also occur acutely and be the primary issue, as in complex regional pain syndrome, or amplified pain syndrome, which can happen to anyone but affects more girls and young women.

Importantly, sensitization can affect our guts more than skin, muscles, and joints. Visceral sensitization can be caused by stress, which may be one reason why stress is so closely linked with abdominal pain.

Sensitization is the Boss of All Risk Factors. Most conventional risk factors for common pain problems are surprisingly bad at predicting who’s going to do poorly. When combined with sensitization, they get much more predictive.3 For example, signs of arthritis on a scan correlate poorly with actual pain; but arthritis + sensitization does! That’s a big deal. Fortunately, it is relatively easy to self-asses your own sensitization status: see Sensitization in Chronic Pain: Pain itself can change how pain works, resulting in more pain with less provocation.

Chronic pain does not work like acute pain

Chronic and acute pain are radically different. Chronic pain is not just acute pain that kept going. Over several weeks, the nature of pain changes. Unfortunately, we actually still don’t have a good understanding of how it changes. It probably involves a complex stew of the ideas in this article. For instance, sensitization (see above) is clearly a major factor. Emotional and physical stresses are strongly linked to chronic pain, but we’re not sure exactly how.

Chronic pain can become a kind of “neurological habit,” regardless of whether any tissue is still in trouble.

The “neuromatrix” theory of pain suggests that pain is produced by “widely distributed neural network in the brain rather than directly by sensory input evoked by injury, inflammation, or other pathology. ”4

Translation (and the important thing for desperate patients to understand): chronic pain rarely continues to be driven by tissue in trouble, and starts to become a kind of “neurological habit” — regardless of whether any tissue is still in trouble. In many cases, it’s not! The pain is a kind of ghost of the original, a tormenting poltergeist. The analogy to “phantom limb pain” is strong: it’s like phantom limb pain, but without losing a body part.

The 3 Basic Types of Pain: Nociceptive, neuropathic, and “other”

There are two main kinds of pain: nociceptive and neuropathic. Nociceptive pain is the most familiar because it arises from damaged tissue, like a cut or a burn. Neuropathic is more rare, because it is caused by damage to the damage-reporting system itself, the nervous system. Some pain, like fibromyalgia pain, doesn’t fit into either category, and was historically and poorly labelled “functional pain.” Pain is also either somatic (skin, muscle, joints) or visceral (organs). Read more …

Psychological amplification

Not pain that’s “all in your head” pain, but pain that is seriously “aggravated by your head.” The brain may amplify pain substantially as a consequence of stress, anxiety, fear. Like an ulcer, there can be a physical problem, but one that is also sensitive to your emotional state.5 Sometimes, the brain’s interpretation of a situation becomes a major part of the issue, or even the dominant factor — still not “all” in your head, but “a lot” in your head. Like picking at a scab, the brain can become excessively focused on a pain problem. For more information, see Pain is Weird: Pain science reveals a volatile, misleading sensation that comes entirely from an overprotective brain, not our tissues.

Amplified pain exists near one end of a spectrum: acute pain with a clear cause is at one end, chronic pain driven entirely by the mind at the other. With a clear traumatic trigger, the diagnosis of “amplified” pain seems apt: there was a painful problem originally, it just got exaggerated by the power of the mind. The more disproportionate that amplification gets, the more like pure psychosomatic pain it gets…

All in your head: true psychosomatic pain

Pure all-in-your-head chronic pain is probably quite rare. Unexplained chronic pain is routinely chalked up to psychology. “Patients often find themselves trapped in a zone between the worlds of medicine and psychiatry, with neither community taking full responsibility.” (O’Sullivan) But, in most cases, there’s a diagnosable cause that simply hasn’t been diagnosed yet, and that’s the main reason this article exists. Most pain patients need better diagnosis, not a psychiatrist.

But at least a few probably do need a psychiatrist. Pure psychosomatic pain probably does exist. Some tension headaches are probably good examples of how mental state can directly drive pain with no clear intermediate mechanism. Amplified pain is a much more extreme example, which makes it quite clear that psychological factors can dominate chronic pain. The phenomenon of functional neurological disorder (FND, formerly known as “conversion” disorder) makes it even clearer: seizures, paralysis, blindness, and other neurological symptoms in the absence of neurological disease.67 Strange but true! If we can paralyze ourselves with our minds, we can probably make ourselves hurt too, although this is surprisingly unclear. In fact, some chronic pain might actually be one of the members of the FND family, just undiagnosable — because pain can have so many other causes (whereas seizures, paralysis, and blindness have relatively short lists of possible causes to eliminate, leaving only the power of the mind to explain the problem). No one really knows.

Even the most psychological of all cases of chronic pain likely still have a seed, something that originally inspired the pain, making them extreme cases of “amplified pain” (see previous section), and not technically “pure” psychosomatic pain. But if the trigger is subtle enough, relative to the psychosomatic consequences, then it’s psychosomatic for all intents and purposes, and the trigger no more defines the problem than a grain of sand defines a pearl.

Pain with literally no specific cause, especially just poor health

Like other complicated things in life, pain may not have any specific cause at all. Although we often speak of pain being multifactorial, we still tend to assume that just one of those factors is the specific cause of pain, and the other stuff — sleep loss, stress, etc — is just piling on, making a bad situation worse. That picture may be wrong: some chronic pain is probably an emergent property of a big mess of synergistic stresses and poor health and fitness, with literally no specific cause. It may crop up only with an unholy combination of many factors. This is a systems perspective on pain and malaise.

How does nothing in particular actually make us hurt? There are two main neurobiological suspects: sensitization and neuroinflammation lower our thresholds for pain and malaise. They can occur independently but are usually entangled. They are certainly set in motion by major trauma and disease, but — and this is the systems perspective — probably mainly just by being really out of shape, our health and fitness ground down by many forces. There are definitely cases of pain with “no specific cause” in seemingly fit people, but not many, and many of them probably are simply unfit in non-obvious ways.

Major factors in poor health — sleep deprivation, smoking, obesity, social isolation — are all well known to correlate with pain, and all of these get more attention below. But the general principle of pain without any particular cause is very important, and poor health and fitness is probably the most important example of how that works. It may be a good news scenario in the sense that it might be treated by simply getting into shape. But it’s bad news in the sense that getting into shape is often a lot easier said than done.

See Vulnerability to Chronic Pain: Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems.

“Spasms”: cramps, dystonia, spasticity, etc

Muscle tissue is everywhere — our most massive biological system — and its subtler hijinks can cause a lot of discomfort without giving itself away. No one has any doubt about the cause of pain when they get a massive calf or foot cramp, but not all cramps are so obvious, and there are other types of insidious, uncomfortable muscle contractions.

This is a broad category of trouble, which contains a number of specific examples, some of which are discussed below, like “trigger points” and the “multiple sclerosis hug” (spasticity of the ribcage), and vaginismus (spasticity of the vaginal and pelvic floor muscles). Using just a wide brush for now, the types of unwanted contractions that cause the most trouble without being easy to diagnose are cramps, dystonia, and spasticity. “Spasm” — as in a “back spasm” — is an informal and non-specific term that could be used to “explain” a lot of musculoskeletal pain, and could refer to any of the more specific types of pathological contractions.

Fun fact: if your muscles are contracted for long enough, they will actually “freeze” like that: essentially scarred into place, a phenomenon called “contracture.”8

See Cramps, Spasms, Tremors & Twitches: The biology and treatment of unwanted muscle contractions.

Referred pain

Referred pain results in an amazing amount of medical barking up the wrong tree.

Anything that hurts inside the body — anything deeper than skin — is harder for the brain to locate. This is partly because we literally just don’t have enough nerve endings for it, and partly because the nervous system isn’t perfect and signals literally get “crossed.” The practical result of this is that internal pain with any cause may be felt somewhere completely different. Despite the fact that this phenomenon is well known, it still results in an amazing amount of medical barking up the wrong tree. Referred pain isn’t exactly a “cause” of pain, but it belongs in this list because it’s an important concept that can help to explain many pain problems that otherwise don’t make sense. For instance, both of the examples at the beginning of this article were cases where referred pain fooled doctors — in both cases, the pain was caused by a trigger point in a nearby muscle, not by vital organs. The doctors simply looked in the wrong place!

Spatial summation and why some body areas suffer more, like the neck and back

If five bees stung you all at once, in one small area on your back, you would probably think you had been stung by one super-bee (or maybe that you’d been poked with a cattle prod). Two sources of pain close together will be felt as one larger painful spot, a neurological effect called “spatial summation.” Pain perception is low resolution, and the brain can merge pains that are up to 20cm apart.9 This might explain why some areas of the body, like the neck and back, are more prone to pain: either the brain can “sum” more widely spaced sources of pain in some places than others, and/or some areas simply have more to sum up, more potential sources of pain. Just recently, research showed that we have roughly the same perceptual “resolution” for pain everywhere in the body,10 so the spine is probably not a common trouble spot because we cast a wider summation net there. This makes it even more likely that there’s just more to sum in the spine: lots and lots of tissues that often have minor problems, which get perceived as a smaller number of worse problems. This could also help to explain the chronicity of spinal pain: if you have “one” back pain problem that is actually coming from two nearby sources, you’re going to think you have the same back pain problem until both sources are relieved, which is probably going to take longer.

The pain of stuckness

Here’s a simple experiment: assume an awkward posture and stay there. How long can you last? Within an hour you will probably be in severe pain. Why? You haven’t actually damaged anything! But we seem to be wired to avoid stagnancy, probably because every cell in our body depends on nearly constant movement to survive. The exact mechanism of pain is probably nerve endings that detect tension on cartilage, ligaments, and tendons, and which in turn is interpreted by the brain as a surprisingly serious threat. But here’s the kicker: this effect is potent enough that it can be triggered without an obviously awkward posture. It can be caused by surprisingly subtle postural stresses (like from poor ergonomics), or anything that deprives tissue of full movement. When a joint feels “stuck,” for instance, and there is no obvious way (and sometimes no anatomical way) of moving to get “unstuck,” the sensation can escalate to a screaming itch-you-can’t-scratch. This may be the main cause of neck cricks, for instance, and scads of other miscellaneous aches and pains.

##Pain as a learned response (classical conditioning)

Some chronic pain may be a “learned response” to things that shouldn’t hurt, like Pavlov’s dogs salivating to the ring of a bell — classical conditioning. It’s an interesting idea, with obviously optimistic implications, because what is learned might also be un-learned. Classical conditioning is not widely believed to be a factor in chronic pain, but it’s broadly plausible, with several lines of reasoning and evidence that point straight to it (without taking us all the way there).

For instance, it’s already well-established that people can have truly serious pain experiences as a response to the perception of threats that don’t actually exist, like the one about the guy who was in agony from a nail that had been driven through his boot… but it had actually gone between his toes. Such stories are a novelty when the illusion of danger can be definitively dispelled, but threat perception is usually messier — and likely to crop up again and again in response to subtle sensory cues. If you always respond the same way to the same stimuli, boom, that’s a perfect setup for classic conditioning. That’s how we might “learn” to hurt.

No one knows if or how much this actually occurs, but it’s a fascinating concept, and I consider it a neglected area of research. For much more information, see: Chronic Pain as a Conditioned Behaviour: If pain can be learned, perhaps it be unlearned.

A genetic defect that exaggerates all sensations (pain included)

This is just one of several possible causes of sensitization (discussed above), but it deserves to be singled out because it’s so interesting: some cases of chronic pain may be partly or entirely caused by a common genetic defect,11 a good specific example of how unexplained pain is linked to genetics.12

This glitch results in low levels of the neurotransmitter serotonin, which appears to exaggerate bodily sensations, which is rich soil for chronic pain to take root in. Patients with unexplained chronic widespread pain are notorious for having many, many other odd symptoms. All of those feelings in a body are high-potency hypochondria fuel that can really freak people out, which is probably why such patients often seem like “drama queens” and are considered “difficult.” Unsurprisingly, that uncharitable explanation is probably often wrong, and this genetic disease is a really excellent demonstration of why.

And it’s a common genetic defect, mind you. Not rare. At ten percent of the population, it’s about five times more common than red hair. Wow. Read more.

Stupid, stupid neutrophils

Neutrophils are defender cells that are supposed to destroy bacteria that invade wounds, a normal part of the inflammatory response to injury. Bizarrely, neutrophils go to work even when the wound is sterile, not open to the outside world. Like an overzealous police force with nothing better to do, they also attack a common cellular organ, mitochondria, whenever it is spilled from cells by injury. Mitochondria are actually honoured symbiotic guests that convert our food to energy for us. Normally we live out our lives in perfect harmony with mitochondria, biological BFFs. But when they get the chance, neutrophils target and hunt them like they are invaders13 because for millions of years they haven’t gotten the evolutionary memo that mitochondria should be left in peace.

Inflammation often seems excessive because it is, because every trauma causes pain that is too loud for too long, because a significant portion of the inflammation is due to this SNAFU immune system policy of attacking mitochondria. There are many perverse sources of pain in pathology, but this one really stands out as being particularly ridiculous and unfair. It does have one practical implication: it directly suggests that it’s quite reasonable to try to control and limit inflammation with things like Voltaren and icing. Contrary to the popular notion that inflammation is “natural” and therefore good, inflammation is definitely exaggerated, and could do with some controlling!

For more information, see Why Does Pain Hurt? How an evolutionary wrong turn led to a biological glitch that condemned the animal kingdom — you included — to much louder, longer pain.

Chronic systemic inflammation and “inflammaging”

Chronic, subtle, systemic inflammation may be a factor in stubborn musculoskeletal pain (as well as much else). We get more inflamed as we age, a process quaintly known as “inflammaging” (for real). This may be the way that some of the other things discussed here actually cause trouble, or it may be an independent phenomenon. Inflammaging correlates strongly with poor fitness and obesity, also known as metabolic syndrome, the biological precursor to diabetes and heart disease. And that, in turn is linked to chronic psychological stress, and of course biological stresses like smoking and sleep deprivation. Basically, the “harder” we live, the more likely inflammaging and metabolic syndrome get.

There are several other unproven but plausible reasons why inflammation escalates as we age. Each of these deserves its own discussion as yet another way that we may end up in pain, but they are also quite speculative, so for now I’ll just lump them together as “possible causes of inflammaging.” For more thorough discussion of these possibilities, see Chronic, Subtle, Systemic Inflammation.

• the accumulation of permanent minor infections
• lasting collateral damage from past infections
• environmental pollutants

It’s important to bear in mind that inflammation per se not the enemy, but rather whatever pathological cause for its excess. And note that neuro-inflammation specifically is strongly linked to chronic widespread pain.

Unexplained neuropathy (especially channelopathy)

“Neuropathic” pain is the ultimate false alarm: pain caused by trouble with the nervous system itself. It’s the difference between engine trouble and trouble with that light on your dashboard that says there’s engine trouble.

There are some quite blatant neuropathic pain problems, such as spinal cord impingement (discussed below), but humans also suffer from a surprisingly high rate of unexplained and/or subtle neuropathies, where the pain-reporting system is just kinda a bit wonky. Neurologists are often stumped by their patients.

Up to one-third of people seen in an average general neurology clinic have neurological symptoms that cannot be explained and, in those people, an emotional cause is often suspected.

It’s All in Your Head, by Suzanne O’Sullivan, 9

Suspected but probably often wrong (see psychosomatic pain). Specifically, a lot of this trouble may be driven by channelopathy, which is a poorly understood type of neurological trouble related to “dysfunction of ion channels located in the membranes of all cells and many cellular organelles.”14 In other words, poorly understood glitchiness at the very tiniest scale of biology. What it boils down to is that sometimes nerves “fire” for no apparent reason, causing all kinds of trouble, including false alarm pain.

This is probably not one disease. It’s likely that unexplained neuropathy has many pathological explanations, if only we could see them. “Channelopathy” may never be its own diagnosis: it’s just a likely but hypothetical type of problem that’s basically still beyond the power of medicine to deal with. See also neuroinflammation and mitochondrial disease, other possible root causes of puzzling neurological problems.

Neuroinflammation

Imagine an inflamed nervous system — it’s probably just as unpleasant as it sounds! In fact, it is nearly synonymous with feeling sick. Neuroinflammation is a major reason why we feel exhausted, fragile, and weak when we’re in medical trouble. It’s most obvious after severe infections and major injuries. The immune system’s reaction to illness and injury is exploited to irritate the nervous system, with the goal of making us feel too awful to overdo it while trying to heal. This happens to all animals, and always has.15 It’s a very basic feature of biology, not a bug.

What we’re only just beginning to understand is that it can be more subtle and insidious. It may have non-obvious causes, or happen more than it’s supposed to (like an autoimmune disease). Even more exotic, the human mind may even be capable of triggering it with the perception threats to our health (e.g. severe chronic stress, see the “systems perspective”). Like stress itself, neuroinflammation is a generalized response — regardless of the trigger, the system has the same effect.

This may explain how many baffling symptoms work,16 even just hurting too much. What better way to force an animal to take it easy than to make everything hurt too easily? Neuroinflammation probably drives “sensitization” — lowered pain thresholds, basically.17

Non-obvious nerve entrapment

Usually when you have a pinched nerve, the symptoms are obvious: zinging “electrical” pain, tingling, and numbness are the signatures of a distressed nerve. Unfortunately, peripheral neuropathy does not always announce itself so clearly. Sometimes all you get is pain.18 This predicament usually leads to a wild goose chase for more “mechanical” causes of pain. Consider this remarkable case study of cluneal nerve entrapment…

The cluneal nerves pass from the low back and sacrum into the buttocks, just under the skin, and they can get tangled up with ligaments and connective tissue on their way, potentially causing chronic low back pain. In 2016, Aota reported on “a case of severe low back pain, which was completely treated by release of the middle cluneal nerve. ”19 Exploratory surgery identified nerves “entrapped in adhesions.” They cut them free … and that was the ticket. The patient was decisively cured. Which is pretty cool. But that was after years of suffering, and a pointless surgery on her intervertebral discs.

As straightforward as that example is, it is also possible that her problem was not the nerve “snag” per se but a biological vulnerability to feeling it. It’s likely that nerve entrapments only cause trouble when combined with other hard-to-diagnose problems… like some of the other things in this article. No one really knows.

Loneliness, social isolation, and “social distance” (and not the way we mean it in the pandemic)

Social isolation — “loneliness” if you’re unhappy about it — is a major general health suppressor in the same league as other major vulnerabilities like sleep deprivation or smoking.20 It almost certainly involves increased vulnerability to chronic pain as part of the deal. 21 We do know that sensitization and pain chronicity are driven by catastrophization and social factors, and injury and disability are going to seem more threatening — more “catastrophic” — to people without good social connections, all other things being equal.

It can be tough to make friends, stressful even, and often it’s hardest for the people who need it the most22 — but it’s a worthwhile investment.

The term and related concept of “social distancing” was hijacked by the COVID-19 pandemic. It used to refer to the chasm between social classes. Inequality and prejudice undermine health in many insidious ways, including “loneliness,” but definitely not limited to it. See Chronic Pain and Inequality (“Physical distancing” is the better term in the context of disease prevention!)

Smoking (probably just a major proxy for “poor health”)

Smoking doesn’t hurt per se — not directly — but smokers hurt. Smoking has already come up in the context of things that probably increase systemic inflammation, which is likely a major way that it increases the risk of pain. However, it’s such a powerful independent predictor of pain23 — that is, smokers are quite a lot more likely to suffer from pain, regardless of anything else about their health status — that it probably does its dirty work in multiple ways, and should be called out as a cause of pain in its own right. That seems reasonable for anything that makes several types of pain two to three times more likely.

Most likely this is just yet another strong sign that poor health is the real problem, which works in many ways, and almost any amount of smoking just guarantees poor health. See Smoking and Chronic Pain.

Muscle Knots

Most of us have some unexplained sore sports, which mainly feel like sensitive muscle tissue (but also tendons and ligaments). And some of us have a lot of them.

These are often called muscle knots informally, or “myofascial trigger points” only slightly more formally (and many other names over the decades). They seem to be involved in a lot of the world’s aches and pains. No one doubts that the sore spots exist, but many doubt what they are: their biology is still mysterious and contentious. Conventional wisdom says they are basically tiny cramps, but they might also be more of a sensory glitch. Regardless, they are often associated with strong pain that often spreads in confusing patterns (referred pain), and they grow like weeds around other painful problems and injuries, making them clinically interesting and tricky. Although well known to many specialists and researchers, most doctors and therapists know little about them, so misdiagnosis is epidemic.

There’s good news: as common and vexing as these sore spots are, many seem to be relieved by a bit of simple stimulation, just a little rubbing, like scratching an itch. For a basic primer, see Basic Self-Massage Tips for Myofascial Trigger Points. For an insane amount of information, see my book on this topic: The Complete Guide to Trigger Points & Myofascial Pain.

Complex regional pain syndrome (CRPS), the most extreme specific form of sensitization

Most pain “sensitization” — lowering the pain threshold — is a normal, temporary reaction to injury, a common, and temporary state. You cut your finger and the tissue around the cut is much more delicate while it heals.

But sometimes this reaction spins out of control, becoming a disease in its own right. The most extreme example of this phenomenon is complex regional pain syndrome, which causes extreme pain, usually in a limb, and usually following some relatively minor tissue insult like an insect bite, a minor cut, or a small fracture.

When it’s full-blown, the severity of this problem is impossible to understate (suicide is a tragically common result), and yet there almost certainly are milder variations of it. Many times in my career I have become quite convinced that a patient had to be suffering from some lesser form of CRPS, awful but not enough to clinch a CRPS diagnosis.

Whenever something painful happens to me, amid all the distress I am surprised at being reminded of how painful pain is. That thought is always followed by another, “What if I hurt like this all the time?” Chronic pain syndromes are extraordinarily debilitating.

Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, p. 396

Myelopathy and dysautonomia

An irritated spinal cord — usually irritated by being slightly pinched by a narrow spinal canal — can cause an astonishing variety of problems, including pain, without ever clearly giving itself away. Symptoms can be in virtually any location in the body, if the location of the trouble is high in the spine. This can go on for years, bad enough to cause pain but never bad enough to be easily diagnosable.

Worse, there’s some intriguing evidence that “minor” irritation of the upper spinal cord may be uniquely problematic, causing “dysautonomia” — excessive sympathetic arousal, causing you to react as if stressed.24 This weird low-grade crazy-making effect is new and still uncertain, but it is nicely consistent with the much firmer, recent discovery that the autonomic nervous system is very disturbed in the aftermath of major spinal cord injuries, causing organ failure25 — a clinical reality historically overshadowed by the seriousness of paralysis. Subtle dysautonomia from chronic mechanical irritation of the spinal cord is definitely a plausible, sinister, and thoroughly obscure explanation for some chronic pain and anxiety.

Claudication: the pain of impaired blood flow

Sometimes an artery gets narrowed or pinched off and causes serious pain. Although simple in principle, it tends to get missed in younger people, where it’s a relatively rare problem, and so the suspicion falls on other things. It also gets missed because “musculoskeletal” is a realm of medicine where circulatory function is rarely considered at all. But it should be an easy diagnosis: claudication tends to cause a deep aching pain exclusively with exertion (when tissues are demanding oxygen), which isn’t how most musculoskeletal problems behave. Sometimes it is easy, like a straightforward case of a cyclist with a couple months of leg pain and weakness with exertion.26

And sometimes it’s not easy…

A patient had sciatica-like leg pain for thirty-five years and was misdiagnosed many times until finally getting not only a definitive diagnosis but a cure. 27 He had a narrowed artery (arterial stenosis causing “claudication,” the pain of impaired circulation). That’s it! Not even a difficult diagnosis in the end, really. There were some pretty glaring clues there that got ignored by a lot of people who should have known better.

But not only was he misdiagnosed many times over more than three decades, he was misdiagnosed fashionably: that is, each misdiagnosis neatly fit a paradigm in physical therapy (better than it fit his symptoms). This carried on right up to and including the present day fascination with psychosocial factors and sensitization (which served him no better than any of the other paradigms had). Taylor and Kerry:

Interestingly, the patient’s belief that something ‘was actually wrong’ had remained with him throughout the journey. This, of course, had been explained away to him (more recently) by current research and evidence-based thinking on central sensitization and pain.

Just fascinating. The authors thoughtfully explore the implications of this rather shameful episode. The bottom line? Good diagnostic skills are never out of fashion. Or shouldn’t be, anyway!28

Hypermobility spectrum disorders and Ehlers–Danlos syndrome

Hypermobile patients get hurt easily and have a lot of chronic body pain.29 There are many types of hypermobility, with a wide range of severity, from trivial party trick flexibility in one or two joints (“double-jointed”) with no apparent consequences — especially early in life — all the way to full-blown genetic disorders of the connective tissue with many serious medical consequences. There’s a huge grey zone in the middle of under-diagnosed and under-treated people, who are definitely having problems but may never figure out why or what to do about it.

Hypermobility spectrum disorders (HSD) are a group of conditions defined by joint hypermobility — unexplained joint looseness. HSD is a bucket diagnosis for people with symptomatic hypermobility, but without a connective tissue disorder that explains it, like Ehlers–Danlos syndrome or Marfan syndrome. Most connective tissue disorders are relatively obvious, but EDS can easily evade diagnosis, making it a prime suspect in many cases of chronic pain…

Ehlers–Danlos syndrome (EDS) is a group of conditions that includes hypermobility along with fragile tissues that injure easily and heal poorly (especially skin), with many consequences. The most common form of EDS is hypermobile EDS (hEDS). It’s tricky to distinguish hEDS from HSD.30 However, hEDS is probably associated with serious rheumatic diseases (i.e. psoriasis, ankylosing spondylitis, rheumatoid arthritis)… and this is fresh science and likely to be missed, “perhaps due to a lack of gravitas surrounding the HEDS diagnosis.”31

Given the musculoskeletal troubles that we know hEDS can cause, it is reasonable to guess that less severe hypermobility (HSD) may also be both clinically important and yet even less obvious.

So, hEDS/HSD is serious … but it’s not taken seriously. Even doctors who know about hEDS/HSD usually assume that it’s mostly a minor condition, and would definitely not refer patients on to a rheumatologist.

Vitamin D and magnesium deficiencies

There is not a single supplement or anti-inflammatory superfood that is clearly beneficial for any common kind of pain, but there are a couple nutritional deficiencies that stand out as significant, legitimate suspects in many chronic pain cases. Pain may be the only clear symptom of either one.

Vitamin D deficiency is on the firmest ground. It is probably more common than once suspected — at least 1 in 20 people in the lowest estimates,32 and possibly many more.33 It can cause subtle widespread pain that may be misdiagnosed as fibromyalgia and/or chronic fatigue syndrome, including symptoms like muscle and bone aching,34 fatigue and weakness, lower pain threshold, and more acute soreness after exercise that is slower to resolve. For more information, see Vitamin D for Pain.

Magnesium deficiency is also a suspected factor in chronic pain, especially migraines.35 Some people are aware that magnesium supplementation is the specific rationale for Epsom salts: a form of getting the stuff into your body that is of very dubious value (especially compared to straightforward oral supplementation). Ironically, magnesium (in a clinical setting) is known to induce cramping and severe muscular pain, so none of this biology is straightforward!

Mitochondrial disease

Mitochondria are the microscopic organs that generate energy, invariably described as the power plants of our cells. They produce energy and, it turns out, they may also distribute it, like a network of power lines.36 Mitochondria can malfunction like anything else in biology: disease on an extremely small scale, of literally microscopic “organs.” There’s still a great deal of research to be done to understand the problems mitochondria have, but we do know that it can cause an astonishing variety of symptoms including chronic pain and, of course, fatigue.37 Although rare, it has even been identified in cases of isolated muscle pain.38

Mitochondrial disease might prove to be the key to understanding some of the mysterious syndromes as well as a deeper explanation for more familiar diseases, especially in neurology. Notably for pain patients, there’s probably overlap between this topic and neuroinflammation and channelopathy, other low-level biological problems linked to chronic pain, like sensitization and neuroinflammation.

Chronic immune activation after infection

You can “win” the battle with an infection and still lose the war, suffering for long after, because some pathogens pollute our biology in a way that does permanent damage. For instance, the Borrelia burgdorferi bacteria causes Lyme disease, but many people continue to suffer even when all the B. burgodorferi are dead — a previously unexplained phenomenon called post-Lyme disease syndrome. The cause is probably a lingering molecule produced by the bacteria during their campaign. In 2019, researchers discovered that B. burgodorferi sheds a peptidoglycan (PGBb) molecule while it grows, which collects in joints especially and continues to provoke an immune system, causing ongoing inflammation and malaise.39 Although “just one study” of a controversial topic, the study was highly persuasive, especially the part where they induced acute arthritis in mice by injecting them with PGBb.

Although the primary symptom is painful arthritis, a chronic immune response like this would also tend to provoke generalized illness — fatigue, malaise, sensitization — via the mechanism of neuroinflammation.

If correct, then this study has solved one of the bigger puzzles in medicine — a big deal — but it also demonstrates an extremely important general principle: immunity is a double-edged sword with many, many complications that are impossible to guess. If this can happen, and avoid detection for decades, you can be damn sure there’s more like it.

Syphilis

Yes, believe it or not, syphilis can actually be a stealthy cause of pain. The first sign of syphilis is a lesion that is often minor and easily missed: usually painless, often inaccessible, nearly identical to a canker sore when it’s in the mouth. The second stage consists a few weeks of malaise and rashes. If the rashes aren’t clear enough, this stage is often mistaken for the flu or just an inexplicable phase of the blahs. The disease then goes dormant to some degree, for years, or forever, but in some people it will develop into the final stage, which is where the chronic aches and pains may develop (just one of a great variety of possible symptoms). It’s a slow disease that can affect many organ systems, so diagnosis often takes a long time, despite frank pathology that can be easily diagnosed with the right tests. Some patients with unexplained chronic widespread pain (fibromyalgia) probably have syphilis.

Facioscapulohumeral Muscular Dystrophy [early stages]

I have a good friend, someone I’ve known for most of my life, who has this common and usually mild form of muscular dystrophy. It was undiagnosed for decades because the symptoms were subtle and he wasn’t even trying to figure it out. By his late 30s, his upper trapezius wasting away, he was initially misdiagnosed with frozen shoulder among other things, until he finally got the correct diagnosis — and then he started to see how the disease explained an awful lot about his life, many experiences and personal “quirks”… like a lifelong tendency to excessive soreness after exercise!40

Even his father’s life made more sense: the disease is genetic, and he obviously struggled with it, stoically, undiagnosed from cradle to grave. Biology is destiny, and this condition is a really good example of it. How many people out there are in that multi-decade period of wondering why they get so sore so easily, before finally being diagnosed with FSHD?

Autoimmune diseases [early stages]

The autoimmune diseases are a huge class of pathologies that can cause essentially any non-specific symptoms for a long time before diagnosis. These are conditions like lupus, rheumatoid arthritis, celiac disease, inflammatory back pain (spondyloarthritis, a common cause of the phenomenon of morning back pain), and many, many more. Lupus is one of the most common and notoriously unpredictable and slow to develop. Some people with a variety of weird aches and pains and other symptoms are going to end up getting diagnosed with lupus eventually, but it can take literally years for the situation to clarify. It’s a classic hypochondriac’s diagnosis, because of its many possible vague symptoms that overlap with anxiety symptoms.

Also note the interesting possibility but that subtle/atypical autoimmune disease may be synonymous with excessive “inflammaging” (the systemic inflammation that affects us all as we age, but too much and too soon in some people).

Multiple sclerosis prodrome [early stages]

Another classic hypochondriac’s diagnosis, multiple sclerosis is all too real, and the most common autoimmune disorder of the central nervous system. So it’s another autoimmune disease, but it’s one that is particularly common, serious, and prone to causing pain and other woes well before diagnosis. It definitely does not cause primarily pain in every patient; the classic onset of multiple sclerosis is more blatantly neurological in character (tingling, numbness, weakness, and so on). But some patients definitely start with pain, and spasm is the primary mechanism. One particularly good and sinister example: the “MS hug,” which feels like a painfully tight band around the chest. Although the feeling of constriction is the classic symptom, many patients also just experience widespread and erratic pain in the chest wall, probably from erratic, isolated painful contractions.

A diagnosis of multiple sclerosis usually isn’t anywhere near as slow to come as, say, a lupus diagnosis. It will probably reveal itself sooner rather than later. But there is definitely potential for a period of unexplained pain.

Lymphoma (cancer of the lymphatic system, lymph nodes)

Lymphoma is a cancer of the infection-fighting cells of the immune system, cells in the lymph nodes, spleen, thymus, bone marrow, and other parts of the body. These cells grow out of control. Although relatively easy to treat, as cancers go, it’s also notorious for causing unpredictable symptoms for long periods before diagnosis. There is a classic first sign that’s hard to miss — badly swollen lymph nodes — but quite a few cases are more subtle, mainly just various forms of “the blahs” and a couple more distinctive symptoms like night sweats and itching. The swollen nodes are not painful, and pain is not a classic symptom … but it can happen, depending on where tumours are forming and what they are pressing on, and possibly because of ramped up systemic inflammation.

Reserve a few minutes to read this: “The wilderness of the medically unexplained.” There’s not much in the way of a take-home message here: it’s mostly just a really well-written and heart-wrenching tale of a cancer that flew under the diagnostic radar for quite a while. It’s going to be poignant for anyone who has felt like a medical mystery … so, you know, just about everyone with chronic pain. I’m not sure that anyone involved could have done much better. Things that are tough to diagnose are tough to diagnose, and that’s just life. And death.

But please, doctors (and anyone responsible for diagnosing): try to remember that when you hear hoofbeats in Texas, sometimes it really is bloody zebras, not horses.

Drug side effects

Some drugs are notorious for causing joint and/or muscle pain as a side effect. Other kinds of pain are possible too, but those are usually more distinctive and readily identified as a drug side effect. Joint and muscle pain are easily mistaken for the ordinary aches and pains of aging, removing suspicion from the drugs that are actually causing them. Some of the usual suspects are:

• statins (for lowering cholesterol)
• bisphosphonates (for osteoporosis and Paget’s disease)
• fluoroquinolones (a class of antibiotics)
• retinoids (for skin conditions, like Accutane for acne)
• Trintellix (an antidepressant)

Some of these may actually be innocent, others almost certainly do cause trouble: it’s surprisingly unclear, like most of medicine. Here’s some more detail about statins and bisphosphonates …

Actonel (risedronate) is one of the more popular bisphosphonate drugs, any of which may cause severe musculoskeletal pain years after first exposure.

The bisphosphonates — On January 7, 2008, the U.S. Food and Drug Administration alerted health care professionals and consumers to the unusual severe side effects of a popular class of drugs for osteoporosis and Paget’s disease, the bisphosphonate (Wikipedia). They can cause “severe and sometimes incapacitating bone, joint, and/or muscle pain” which “may occur within days, months, or years” after first taking the medication. This medication has almost certainly explained some otherwise inexplicable pain in some of my patients over the years! Alendronate and risedronate (Actonel) are the two most popular bisphosphonates, and they are usually prescribed for osteoporosis or for a bone-deforming condition called Paget’s disease. If you are 40+ and grappling with a mysterious pain problem, check your medicine cabinet for bisphosphonates in particular, but of course any other medication that could cause pain as a side effect.

The statins — The drugs that lower our blood cholesterol, like Lipitor and Crestor, may also cause pain. Statins are important and widely used drugs, and their deleterious effect on muscle is widely considered a diagnosable condition: statin myalgia, or statin-associated muscle symptoms (SAMS).41 A few patients, about 1 in 10,000, get a more obvious, serious case of muscle poisoning, rhabdomyolysis,42 and an even rarer and more serious condition afflicts 1 in 100,000: statin-associated autoimmune myopathy.4344

And yet there is also confusion and controversy about the prevalence of statin myalgia.45 There’s even clear evidence that it could be some kind of illusion or misunderstanding: in one head-scratcher of a study, taking statins only increased pain when patients knew they were taking statins.46 So that’s weird! The truth is probably “all of the above” and “it’s complicated” — it seems likely that some patients are genuinely intolerant of statins, while others are suffering from fear of statins and/or some other cause of musculoskeletal pain (of which there are many). There might also be some tricky X-factors, like vitamin D deficiency, which seems to be linked to statin myalgia.47

Fortunately, for the genuinely statin intolerant — and you probably do exist! — it’s easy to solve by lowering the dose or switching to another statin.

Opioid-induced hyperalgesia

This is basically the mother of all side effects, with a generous dose of tragic irony.

Opioids are, of course, the cause of an enormous amount of misery and controversy right now. Most people assume opioids are “powerful medicine,” and of course they are in some ways, but what few people realize is that they are surprisingly ineffective for many kinds of chronic pain, completely ineffective for a fairly high percentage of the population with a certain gene … and they can backfire in anyone. “Opioid induced hyperalgesia” is a nasty fate in which opioids actually cause pain instead of relieving it.48 It’s so counter-intuitive that many people on opioids take a long time to figure out that their “pain medication” is causing pain.

Medication-overuse headache (formerly known as “rebound” headache)

This almost counts as a drug side-effect, but it’s an important enough phenomenon in its own right that it deserves separate description. When you take a lot of analgesics — pain-killers — it’s possible to pre-empt the production of your body’s own pain-fighting molecules. Endorphin production, for instance, will drop. This can have disastrous consequences when you stop taking the drugs, resulting in worse pain than ever. It mainly seems to cause headaches, but it’s disturbingly possible that it can make other kinds of pain worse as well. This is part of the phenomenon of the well-known serious withdrawal symptoms from some drugs; it is a less well-known problem with over-the-counter pain-killers. Although this phenomenon isn’t particularly mysterious or difficult to identify, it does show us something important about how pain works: we aren’t entirely without our own defenses, and those defenses can actually be undermined by artificial help. And there are scenarios where analgesic rebound may be difficult to detect. Given how extremely common analgesic usage is, it’s likely that people with recurrent headaches may be suffering primarily from bouts of rebound pain, occurring in the occasional gaps between erratic but generally intensive self-prescribing of pain killers.

I have a good story about a terrible withdrawal-induced headache: see my headache tutorial. For more about all kinds of pain-killers, see The Science of Pain-Killers: A user’s guide to over-the-counter analgesics like acetaminophen, ibuprofen, and more.

Benzodiazepine withdrawal syndrome

The benzos, Valium and many others, are potent tranquilizers, which sedate us by simulating a flood of an important neurotransmitter that is one of the body’s built-in sedatives. We can quickly develop powerful physical dependence on benzos, and rushed withdrawal is notoriously brutal. Withdrawal symptoms can even develop while we are still taking the drug, going a little bit into withdrawal before the next dose, which basically causes erratic and minor but frequent withdrawal symptoms.

In benzo withdrawal, you are the opposite of tranquilized: you’re anti-tranquilized. Huge chunks of your biology are way too excitable. The list of potential side effects is endless — benzo withdrawal is notorious for the freakish variety of symptoms it causes — but they all revolve around a strong theme of jittery misery, like being over-caffeinated but more extreme. Sensory distortion in general is the rule, and everything hurts more than it should.

In some people, withdrawal symptoms are long-term. It’s unclear what the mechanism for this persistence is, but it’s likely that the ferocity of withdrawal results in a poorly calibrated pain system (sensitization), and a tough neurological tailspin to pull out of. Another way of putting it is that withdrawal is basically so surreal and traumatic that it can permanently disrupt our nervous system’s ability to interpret stimuli, especially threatening stimuli, leading to long-term erratic false alarms.

Chronic pain as a destiny: many causes for many years!

Nothing’s ever simple and chronic pain least of all: it’s usually caused by a sinister stew of factors that eat away at people for a long time. Chronic pain may be “destiny” with roots going back many years, even decades.49 Trying to solve it by fixing one thing — like vitamin D, say — may be about as feasible as trying to fix a broken engine with just one tool. It can be an impossible puzzle to even understand, let alone treat. Elisa Arnaudo:

Medically unexplained symptoms (MUS) represent a major challenge for healthcare systems in industrialised countries. These symptoms are so prevalent that they are assessed in up to 50% of consultations in primary care.

Probably almost all MUS involve chronic pain, and Arnaudo’s post seems to be mostly about fibromyalgia. She proposes MUS patients are a stumper because of “an inadequate explanatory framework of disease.” In other words, we’re not just missing some pieces from a puzzle; it’s that we probably don’t even know what kind of puzzle we’re looking at.

And … not necessarily such a puzzle.

Ending with a ray of hope

It’s also possible that many of the explanations we need are really hovering just out of our current reach, and really not so tricky after all — just too subtle to be easy. They get missed not because the problem requires godlike medical insight, but because most doctors just don’t know that much about chronic pain and economics keeps appointments relatively short and so even some pretty straightforward things just get missed.

That possibility is the inspiration for this article. Some of the ways to hurt described above may be the main factors, or even the only factors, for some people.

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Appendix: Two stories of diagnosing mysterious pain

Some extraordinarily desperate people came to see me when I was working as a massage therapist. Two memorable examples:

1. A woman spends three days in the hospital with severe abdominal pain, but is cleared of every possible ominous medical cause … and then comes to see me?! A massage therapist!
2. A man gets a ride in an ambulance with severe chest and left shoulder and arm pain, but doctors cannot find anything wrong with him … and then he comes to see me.

I got lucky with both of these cases, and I was able to treat both of them quickly and easily. There are many ways to hurt, and success was hardly guaranteed. I saw many patients with strange pains I was never able to diagnose. But both of these cases involved surprisingly clear and treatable trigger points: hypersensitive spots in muscle tissue, causing more pain than anyone thought possible.

In the woman’s case, the trigger point was in her iliopsoas muscle, a muscle deep in the abdomen and extending downward through the pelvic that is the subject of much hype and legitimate skepticism. However, it is possible to massage it in some patients. There’s very little to tell: I guessed that it might be the problem, found the trigger point, gently massaged it for a few minutes … and that was the end of her misery. Just like that!

The man’s case was even more straightforward: he had a trigger point in his pectoralis major muscle. It was easy to find, as the muscle twitched violently when I palpated it, the most robust example of a “jump sign” I ever saw. It was nasty, but in twenty minutes of massage we reduced the “heart attack” pain by 80%. The next day it was gone, and it stayed gone for as long as I knew him — years after that. I tell his story in more detail in my trigger points book.

Related Reading

• Why Does Pain Hurt? — How an evolutionary wrong turn led to a biological glitch that condemned the animal kingdom — you included — to much louder, longer pain
• Pain & Injury Survival Tips — Dozens of ideas (and links) for evidence-based rehabilitation and self-treatment for common pain problems and injuries
• A Rational Guide to Fibromyalgia — The science of the mysterious disease of pain, exhaustion, and mental fog
• Chronic, Subtle, Systemic Inflammation — One possible sneaky cause of puzzling chronic pain
• Chronic Pain and Inequality — The role of racism, sexism, queerphobia, and poverty in health and chronic pain
• Anxiety & Chronic Pain — A self-help guide for people who worry and hurt
• Sensitization in Chronic Pain — Pain itself can change how pain works, resulting in more pain with less provocation
• Pain is Weird — Pain science reveals a volatile, misleading sensation that comes entirely from an overprotective brain, not our tissues
• Chronic Pain as a Conditioned Behaviour — If pain can be learned, perhaps it be unlearned
• Vulnerability to Chronic Pain — Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems
• The 3 Basic Types of Pain — Nociceptive, neuropathic, and “other” (and then some more)
• Pain Relief from Personal Growth — Treating tough pain problems with the pursuit of emotional intelligence, life balance, and peacefulness

What’s new in this article?

Twenty-five updates have been logged for this article since publication (2007). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets PainScience.com apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.

I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

Aug 5, 2021 — Added a section about pain as a learned behaviour (classical conditioning).

July — Added a small but good citation to a case study of circulatory impairment in a cyclist causing leg pain (Brindisino).

March — Rewrote the section on neuroinflammation. It had been hastily excerpted and abridged from another article. Now it’s a proper standalone summary and much clearer.

2020 — Added short commentary on the ethics of sharing “high-grade hypochondriac nightmare fuel.”

2020 — Added a section about smoking, expanded the discussion of poor health, and added an interesting blurb about the pre-pandemic meaning of “social distancing.”

2019 — Added new section: “All in your head: pure psychosomatic pain.”

2019 — Added minor-but-nice perspective about the “official” major categories of causes of pain. Pie chart included.

2019 — Added new section about chronic immune activation after infection.

2019 — Two new sections about mitochondrial disease and neuroinflammation, plus a bunch of editing to integrate those topics with some of the others. Also changed the introduction to emphasize that chronic pain is seriously multifactorial, some critical context previously neglected.

2019 — Added a section about a newly identified common genetic defect linked to exaggerated awareness all kinds of sensation. Really fascinating.

2019 — Added section about benzodiazepene (tranquilizer) withdrawal.

2019 — Added section about social isolation and loneliness, the first of a series that I will be adding about non-specific vulnerabilities to illness and chronic pain.

2019 — Added a listed other possibilities that I’m considering for future updates. I think the list itself has value, even without elaboration.

2019 — New section: “Spatial summation and why some body areas suffer more, like the neck and back.”

2018 — New section: “Non-obvious nerve entrapment.”

2018 — New section: “Claudication: the pain of impaired blood flow.”

2018 — New section: “Syphilis.”

2018 — New section: “Pain with literally no specific cause.”

2018 — Major reboot and expansion. This is now a much more comprehensive review of possible causes of pain. There’s more to do and suggestions and requests for additions are very welcome. I hope this will become one of the most useful articles on PainScience.com.

2018 — More information about other drugs with painful side effects.

2017 — Science udpate — Cited evidence that statin myalgia could be bogus, not actually a real problem.

2017 — Added a table of contents. A few minor edits.

2016 — New conclusion, with both discouraging and encouraging perspectives, taken from a recent blog post about the challenge of medically unexplained symptoms.

2016 — Added Vitamin D deficiency and chronic low-grade inflammation.

2016 — Minor addition: a sidebar about “the wilderness of the medically unexplained.”

2016 — Added sidebar about the basic types of pain, nociceptive and neurpathic. Added #10, about exaggerated inflammation.

2007 — Publication.

Notes

1. Painaustralia. The cost of pain in Australia. Deloitte Access Economics. 2019 Mar. PainSci #52620 ❐

2. “Nocebo” is roughly the opposite of placebo: harm powered by belief, instead of relief.

   Latin for “I shall harm” (which I think would make a great supervillain slogan). It refers to the harmful effect of … nothing but the belief in or fear of a harmful effect. Give someone a sugar pill and then convince them you actually just fed them a deadly poison, and you will probably witness a robust nocebo effect. A common funny-if-it’s-not-you nocebo in general medicine is the terror of “beets in the toilet”: people eat beets, and then think there’s blood in the toilet, and call 911. Nocebo is a real thing, and not to be messed with. It is one of the chief hazards of excessive X-raying and MRI scanning, for instance: showing people hard evidence of problems that often aren’t actually a problem.

3. Akin-Akinyosoye K, Sarmanova A, Fernandes GS, et al. Baseline self-report ‘central mechanisms’ trait predicts persistent knee pain in the Knee Pain in the Community (KPIC) cohort. Osteoarthritis Cartilage. 2020 Feb;28(2):173–181. PubMed #31830591 ❐

   Easily identified signs of “central mechanisms” of pain in more than 1400 patients were linked to having worse knee pain a year later. Also, other risk factors had more impact in people with strong signs of sensitization.

4. Melzack R. Pain and the neuromatrix in the brain. J Dent Educ. 2001 Dec;65(12):1378–82. PubMed #11780656 ❐
   

   ABSTRACT

   The neuromatrix theory of pain proposes that pain is a multidimensional experience produced by characteristic “neurosignature” patterns of nerve impulses generated by a widely distributed neural network-the “body-self neuromatrix”-in the brain. These neurosignature patterns may be triggered by sensory inputs, but they may also be generated independently of them. Acute pains evoked by brief noxious inputs have been meticulously investigated by neuroscientists, and their sensory transmission mechanisms are generally well understood. In contrast, chronic pain syndromes, which are often characterized by severe pain associated with little or no discernible injury or pathology, remain a mystery. Furthermore, chronic psychological or physical stress is often associated with chronic pain, but the relationship is poorly understood. The neuromatrix theory of pain provides a new conceptual framework to examine these problems. It proposes that the output patterns of the body-self neuromatrix activate perceptual, homeostatic, and behavioral programs after injury, pathology, or chronic stress. Pain, then, is produced by the output of a widely distributed neural network in the brain rather than directly by sensory input evoked by injury, inflammation, or other pathology. The neuromatrix, which is genetically determined and modified by sensory experience, is the primary mechanism that generates the neural pattern that produces pain. Its output pattern is determined by multiple influences, of which the somatic sensory input is only a part, that converge on the neuromatrix.

5. Weren’t ulcers proved to be caused by a bacteria? That they were. Helicobacter pylori was famously hunted down in 1983 by Australian scientists Barry Marshall and Robin Warren. Although its link with ulceration was initially met with much skepticism, science came around relatively quickly — convinced by evidence, just like it’s supposed to work. By the mid-90s it was widely accepted that H. pylori infection causes ulcers, and Marshall and Warren got a Nobel prize in 2005 (acceptance speech).

   But! Most people infected with the bacterium have no symptoms, and there are many variables that determine the severity of the infection and whether or not it leads to ulcer. Stress is one of those factors (see Guo et al. and Jia et al.). Thus ulcer is very likely both an H. pylori infection and a “stress-sensitive” condition.

6. Espay AJ, Aybek S, Carson A, et al. Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA Neurol. 2018 09;75(9):1132–1141. PubMed #29868890 ❐
7. O’Sullivan S. It’s All in Your Head: True Stories of Imaginary Illness. Chatto & Windus; 2015.

   This book consists mainly of well-told stories of severe psychosomatic illness and functional neurological disorders (neurological symptoms without diagnosable disease). The key take-away is that psychologically powered illness is common and can be amazingly severe. Although Dr. O’Sullivan is clearly concerned about the risk of incorrect diagnosis, and she is cautious and compassionate enough that I think she mostly gets it right (with the notable exception of the chronic fatigue chapter). It’s well-written and fascinating and has plenty to offer. I do wish there were citations.

8. Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol. 2010 Aug;213(Pt 15):2582–8. PubMed #20639419 ❐ PainSci #55265 ❐

   Chronic heel wearers, for instance, do have shortened calf muscles, stiffer Achilles tendons, and a smaller ankle range of motion. It doesn’t actually seem to cause much of a problem, but the tissue does shorten.

   (See more detailed commentary on this paper.)

9. This depends on many other factors. For instance, if you can clearly see that you’ve been struck by two paintballs, 15cm apart, your brain is probably not going to experience one mighty paintball sting — brains are not idiots, and they can use lots of data sources to generate higher fidelity perception.
10. Holbert MD, Pedler A, Camfermann D, Harvie DS. Comparison of spatial summation properties at different body sites. Scand J Pain. 2017 Oct;17:126–131. PubMed #28850365 ❐ These researchers compared summation in the neck and back to the extremities, and found that it works about the same way: in any region, painful sites separated by as much as 15-20cm will be “summed” by the brain, making the entire area feel painful.
11. Khoury S, Piltonen MH, Ton AT, et al. A functional substitution in the L-aromatic amino acid decarboxylase enzyme worsens somatic symptoms via a serotonergic pathway. Ann Neurol. 2019 Jun. PubMed #31177555 ❐
12. Johnston KJ, Adams MJ, Nicholl BI, et al. Genome-wide association study of multisite chronic pain in UK Biobank. PLoS Genet. 2019 Jun;15(6):e1008164. PubMed #31194737 ❐ PainSci #52248 ❐

    This is the biggest study of the genetics of chronic pain patients to date, which found 76 genes that are independent risk factors for multisite chronic pain in 380,000 British citizens. Many of those genes are used in the brain and associated with neuroplasticity, and many were also linked to cell division (very fundamental biological processes). This is consistent with the idea that pain has such deep roots in our biology that it is hard to separate from life, which is why it’s so hard to suppress while also preserving consciousness.

    Almost half of these genes are also risk factors for severe depression, and with some fancy statistical work they showed that pain actually causes the depression but, interestingly, not the other way around — which is probably not evidence that pain is psychologically depressing (although it is), but rather that something about the genetics of chronic pain also leads to depression.

    They also found a bunch of genetic overlap with genes linked to several other diseases: schizophrenia, body-mass index, rheumatoid arthritis and post-traumatic stress disorder, among others.

13. McDonald B, Pittman K, Menezes GB, et al. Intravascular danger signals guide neutrophils to sites of sterile inflammation. Science. 2010 Oct;330mcd(6002):362–6. PubMed #20947763 ❐
14. Kim JB. Channelopathies. Korean J Pediatr. 2014 Jan;57(1):1–18. PubMed #24578711 ❐ PainSci #53026 ❐ “Channelopathies that primarily affect neurons include certain types of epilepsy, ataxia, migraine, hyperekplexia, blindness, deafness, and peripheral pain syndromes.”
15. Lyon P, Cohen M, Quintner J. An evolutionary stress-response hypothesis for chronic widespread pain (fibromyalgia syndrome). Pain Med. 2011 Aug;12(8):1167–78. PubMed #21692974 ❐ This paper explores a striking similarity between fibromyalgia and “sickness behaviour” in animals.
16. Albrecht DS, Forsberg A, Sandström A, et al. Brain glial activation in fibromyalgia – A multi-site positron emission tomography investigation. Brain Behav Immun. 2019 Jan;75:72–83. PubMed #30223011 ❐ PainSci #52325 ❐ This study provides the first in vivo evidence of neuroinflammation in fibromyalgia patients.
17. Ji RR, Nackley A, Huh Y, Terrando N, Maixner W. Neuroinflammation and Central Sensitization in Chronic and Widespread Pain. Anesthesiology. 2018 08;129(2):343–366. PubMed #29462012 ❐ PainSci #52332 ❐
18. It might be accompanied by subtle signs of neuropathy, such as a slight buzzing quality to the pain, but not enough to raise clinical suspicion of a nerve pinch. There’s clearly a range, but at least some significant percentage of cases are not obviously nerve-y.
19. Aota Y. Entrapment of middle cluneal nerves as an unknown cause of low back pain. World J Orthop. 2016 Mar;7(3):167–70. PubMed #27004164 ❐ PainSci #53097 ❐
20. Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed ed. New York: Times Books; 2004. p. 164. “…the fewer social relationships a person has, the shorter his or her life expectancy, and the worse the impact of various infectious diseases. Relationships that are medically protective can take the form of marriage, contact with friends and extended family, church membership, or other group affiliations. This is a fairly consistent pattern that cuts across a lot of different settings. Moreover, these general findings are based on some careful prospective studies and are seen in both sexes and in different races, in American and European populations living in both urban and rural areas. Most important, this effect is big. The impact of social relationships on life expectancy appears to be at least as large as that of variables such as cigarette smoking, hypertension, obesity, and level of physical activity.”
21. Smith TO, Dainty JR, Williamson E, Martin KR. Association between musculoskeletal pain with social isolation and loneliness: analysis of the English Longitudinal Study of Ageing. Br J Pain. 2019 May;13(2):82–90. PubMed #31019689 ❐ PainSci #52275 ❐

    This study looked for a link between chronic musculoskeletal pain, and loneliness and social isolation in several thousand older adults. They found that subjects in pain were actually less likely to be socially isolated, but more likely to be lonely, an interesting apparent contradiction. However, loneliness is probably what matters: that is, social isolation isn’t a problem if you don’t feel socially isolated (lonely).

22. Sapolsky, Why Zebras Don’t Get Ulcers, op. cit.
    

    Take a rodent or a primate that has been housed alone and put it into a social group. The typical result is a massive stress-response. In the case of monkeys, this can go on for weeks or months while they tensely go about figuring out who dominates whom in the group’s social hierarchy.

    Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 406

23. Smuck M, Schneider BJ, Ehsanian R, Martin E, Kao MC. Smoking Is Associated with Pain in All Body Regions, with Greatest Influence on Spinal Pain. Pain Med. 2020 Sep;21(9):1759–1768. PubMed #31578562 ❐
24. Holman AJ. Fibromyalgia and Positional Cervical Cord Compression Differ Only By Autonomic Nervous System Consequences: A Double-Blinded, Prospective Study. Arthritis Rheumatol. 2015;67(suppl 10).

    This paper presents evidence of “minor” irritation of the upper spinal cord may cause “potent sympathetic arousal in humans” — firing up the same branch of our nervous system that handles emergencies. Thirty-one of fifty-four patients with fibromyalgia and positional cervical cord compression showed clear signs of sympathatic arousal.

25. See Sezer, Hagen, Hou, Stein.
26. Brindisino F, Signorelli M, Rizzo S, Heick JD, Maselli F. Lower-Limb Pain Differentiation by a Physical Therapist in an Amateur Cyclist: A Case Report. JOSPT Cases. 2021;1(2):114–123. PainSci #52144 ❐

    Cyclists get plenty of overuse injuries and are usually referred to physical therapists for any persistent pain that doesn’t have an obvious medical cause. In this case, a 57-year-old recreational amateur cyclist had been suffering thigh and leg pain for two months. The patient failed a couple basic tests for endurance of the leg muscles — painful and weak — and had a reduced blood pressure in the lower limb. A blockage in a leg artery was identified and repaired by a surgeon, and the patient fully recovered within three months.

    “Clinicians should consider vascular conditions, even in endurance sports.”

27. Taylor AJ, Kerry R. When Chronic Pain Is Not “Chronic Pain”: Lessons From 3 Decades of Pain. J Orthop Sports Phys Ther. 2017 Aug;47(8):515–517. PubMed #28760092 ❐
28. There are good criticisms of this paper from a couple of my favourite experts and writers, pointing out in a letter to the journal that one of the “fashionable” paradigms impugned here, the biopsyschosocial model, “includes the considerations [the “bio” part] that eventually cured the patient’s pain.” I like the criticism and I like the authors’ response — I see only healthy debate here.
29. Scheper MC, de Vries JE, Verbunt J, Engelbert RH. Chronic pain in hypermobility syndrome and Ehlers-Danlos syndrome (hypermobility type): it is a challenge. J Pain Res. 2015;8:591–601. PubMed #26316810 ❐ PainSci #52758 ❐ Hypermobility is “highly prevalent among patients diagnosed with chronic pain.”
30. “The essential difference between HSD and hEDS lies in the stricter criteria for hEDS compared to the HSD.” But it’s very tricky, and those criteria are all very new (see the 2017 EDS International Classification).
31. Rodgers KR, Gui J, Dinulos MB, Chou RC. Ehlers-Danlos syndrome hypermobility type is associated with rheumatic diseases. Sci Rep. 2017 Jan;7:39636. PubMed #28051109 ❐ PainSci #52757 ❐

    hEDS patients may see multiple subspecialists without realizing a connection between their joint symptoms and multi-systemic involvement of the disease; they are often dismissed as hypochrondriacs, and report feelings of isolation from the lack of diagnosis.

    Perhaps due to a lack of gravitas surrounding the hEDS diagnosis, management of the disease varies among practitioners, and clinical workup does not often extend beyond the joint and skin examination.

32. Manson JE, Patsy M B, Rosen CJ, Taylor CL. Vitamin D Deficiency — Is There Really a Pandemic? N Engl J Med. 2016 Nov 10;375(19):1817–1820. PubMed #27959647 ❐
    

    ABSTRACT

    The claim that large proportions of North American and other populations are deficient in vitamin D is based on misinterpretation and misapplication of the Institute of Medicine reference values for nutrients — misunderstandings that can adversely affect patient care.

33. Holick MF, Chen TC. Vitamin D deficiency: a worldwide problem with health consequences. Am J Clin Nutr. 2008 Apr;87(4):1080S–6S. PubMed #18400738 ❐ PainSci #55028 ❐
34. Bone aching is caused by osteomalacia, which is bone weakening specifically caused by malfunctioning bone building biology. The Mayo Clinic describes osteomalacia symptoms like so: “The dull, aching pain associated with osteomalacia most commonly affects the lower back, pelvis, hips, legs and ribs. The pain may be worse at night, or when you’re putting weight on affected bones.”
35. Mauskop A, Varughese J. Why all migraine patients should be treated with magnesium. J Neural Transm (Vienna). 2012 May;119(5):575–9. PubMed #22426836 ❐ Treating migraines with magnesium is hardly a sure thing, and some object to it, but conservative magnesium supplementation is about as low-risk an intervention as they get — far better than any migraine drug.
36. Glancy B, Hartnell LM, Malide D, et al. Mitochondrial reticulum for cellular energy distribution in muscle. Nature. 2015 Jul;523(7562):617–20. PubMed #26223627 ❐

    For decades, mitochondria have been described as the “power plants” of cells, and they are already fascinating and complex. (I’m particularly amazed by their role in unnecessary inflammation.) But we may need to update the simile: turns out mitochondria don’t just produce energy “like a power plant,” they also deliver it like a network of power lines. This phenomenon was identified in mouse muscles:

    Researchers found that mitochondria in mouse muscles not only produce energy, but can quickly distribute it across the muscle cell through a grid-like network. The findings reveal a major mechanism for energy distribution in skeletal muscle cells, and could provide new insights into diseases linked to energy use in muscle.

    What a wonderful example of how much we still have to learn about muscle tissue (and others too, I’m sure, but muscle seems to be particularly full of surprising puzzles). It seems likely that we probably can’t understand muscle pain properly if we have only just now discovered something so fundamental about muscle biology. Imagine trying to troubleshoot an electrical problem if you weren’t aware of a major feature of how power is generated and transmitted!

37. Meeus M, Nijs J, Hermans L, Goubert D, Calders P. The role of mitochondrial dysfunctions due to oxidative and nitrosative stress in the chronic pain or chronic fatigue syndromes and fibromyalgia patients: peripheral and central mechanisms as therapeutic targets? Expert Opin Ther Targets. 2013 Sep;17(9):1081–9. PubMed #23834645 ❐ “Mitochondrial dysfunction has been shown in leukocytes of CFS patients and in muscle cells of FM patients, which could explain the muscle pain. Additionally, if mitochondrial dysfunction is also present in central neural cells, this could result in lowered ATP pools in neural cells, leading to generalized hypersensitivity and chronic widespread pain.”
38. Filosto M, Tonin P, Vattemi G, et al. The role of muscle biopsy in investigating isolated muscle pain. Neurology. 2007 Jan;68(3):181–6. PubMed #17224570 ❐
39. Jutras BL, Lochhead RB, Kloos ZA, et al. Borrelia burgdorferi peptidoglycan is a persistent antigen in patients with Lyme arthritis. Proc Natl Acad Sci U S A. 2019 Jul;116(27):13498–13507. PubMed #31209025 ❐ PainSci #52327 ❐
40. We know that FSHD causes excessive delayed-onset muscle soreness, often for many years before diagnosis, and without any other symptoms. This is a well-described genetic pathology. There is nothing squishy or uncertain about the diagnosis. And yet the mechanism by which FSHD causes soreness in the absence of any other symptoms is simply unknown. No one knows how FSHD does that. If a disease like FSHD can do it without anyone knowing how, there are surely other pathological ways to be sore without a diagnosis.
41. Di Stasi SL, Macleod TD, Winters JD, Binder-Macleod SA. Effects of Statins on Skeletal Muscle: A Perspective for Physical Therapists. Phys Ther. 2010 Aug. PubMed #20688875 ❐
42. “Rhabdo” is a nasty but also very interesting condition. I discuss it in detail in Poisoned by Massage.
43. Mammen AL. Statin-Associated Autoimmune Myopathy. N Engl J Med. 2016 Feb;374(7):664–9. PubMed #26886523 ❐
44. Regarding classification, professionals should take a look at a great 2004 interview with Eliot A. Brinton, MD: “There are 4 interrelated terms for muscle problems that can occur with statins. Unfortunately, they are often confused even by healthcare professionals … .” (Technical note: this document is freely available, but direct linking will hit a paywall. Medscape only reveals the whole thing to people arriving from a Google search. Simply search for do a Google search for it to get around the paywall.)
45. Ganga HV, Slim HB, Thompson PD. A systematic review of statin-induced muscle problems in clinical trials. Am Heart J. 2014 Jul;168(1):6–15. PubMed #24952854 ❐

    In this review of several statin trials, only slightly more patients had pain on statins than without (placebo): just 12.7%, compared to 12.4%. You could conclude from this data that there actually is no such thing as statin mylagia! But it probably is a real phenomenon, which is highly plausible based on the existence of rarer but very severe side effects on muscle (see Mammen or Statin Therapy). We don’t have very good data about it, it’s mostly not severe, and it’s hard to distinguish from the “background noise” of many other common causes of musculoskeletal pain.

46. Gupta A, Thompson D, Whitehouse A, et al. Adverse events associated with unblinded, but not with blinded, statin therapy in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid-Lowering Arm (ASCOT-LLA): a randomised double-blind placebo-controlled trial and its non-randomised non-blind extension phase. Lancet. 2017 Jun;389(10088):2473–2481. PubMed #28476288 ❐

    This study was designed to test the existence of the phenomenon of statin myalgia. Taking statins did not increase pain in patients when they were unaware that they were taking them. This suggests that statin myalgia is something people get because they are afraid of it, not because it’s a real side effect. As the authors concluded:

    These analyses illustrate the so-called nocebo effect, with an excess rate of muscle-related AE reports only when patients and their doctors were aware that statin therapy was being used and not when its use was blinded. These results will help assure both physicians and patients that most AEs associated with statins arenot causally related to use of the drug and should help counter the adverse effect on public health of exaggerated claims about statin-related side-effects.

47. Michalska-Kasiczak M, Sahebkar A, Mikhailidis DP, et al. Analysis of vitamin D levels in patients with and without statin-associated myalgia – a systematic review and meta-analysis of 7 studies with 2420 patients. Int J Cardiol. 2015 Jan;178:111–6. PubMed #25464233 ❐
48. Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14(2):145–61. PubMed #21412369 ❐
    

    Opioid-induced hyperalgesia (OIH) is defied as a state of nociceptive sensitization caused by exposure to opioids. The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli.

    Clinicians should suspect OIH when opioid treatment’s effect seems to wane in the absence of disease progression, particularly if found in the context of unexplained pain reports or diffuse allodynia unassociated with the original pain, and increased levels of pain with increasing dosages.”

49. Burke NN, Finn DP, McGuire BE, Roche M. Psychological stress in early life as a predisposing factor for the development of chronic pain: Clinical and preclinical evidence and neurobiological mechanisms. J Neurosci Res. 2016 Jul. PubMed #27402412 ❐ “Early-life adversity increases the risk of developing a number of disorders, such as chronic pain, fibromyalgia, and irritable bowel syndrome.”

PainScience.com/ways_to_hurt
PainScience.com/causes_of_pain
PainScience.com/non_obvious_causes_of_chronic_pain
PainScience.com/surprising_ways_to_hurt
PainScience.com/subtle_pathologies_that_cause_pain
PainScience.com/causes

linking guide

Fibromyalgia – Symptoms and causes

Overview

Fibromyalgia is a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain and spinal cord process painful and nonpainful signals.

Symptoms often begin after an event, such as physical trauma, surgery, infection or significant psychological stress. In other cases, symptoms gradually accumulate over time with no single triggering event.

Women are more likely to develop fibromyalgia than are men. Many people who have fibromyalgia also have tension headaches, temporomandibular joint (TMJ) disorders, irritable bowel syndrome, anxiety and depression.

While there is no cure for fibromyalgia, a variety of medications can help control symptoms. Exercise, relaxation and stress-reduction measures also may help.

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Symptoms

The primary symptoms of fibromyalgia include:

• Widespread pain. The pain associated with fibromyalgia often is described as a constant dull ache that has lasted for at least three months. To be considered widespread, the pain must occur on both sides of your body and above and below your waist.
• Fatigue. People with fibromyalgia often awaken tired, even though they report sleeping for long periods of time. Sleep is often disrupted by pain, and many patients with fibromyalgia have other sleep disorders, such as restless legs syndrome and sleep apnea.
• Cognitive difficulties. A symptom commonly referred to as “fibro fog” impairs the ability to focus, pay attention and concentrate on mental tasks.

Fibromyalgia often co-exists with other conditions, such as:

• Irritable bowel syndrome
• Chronic fatigue syndrome
• Migraine and other types of headaches
• Interstitial cystitis or painful bladder syndrome
• Temporomandibular joint disorders
• Anxiety
• Depression
• Postural tachycardia syndrome

Causes

Many researchers believe that repeated nerve stimulation causes the brain and spinal cord of people with fibromyalgia to change. This change involves an abnormal increase in levels of certain chemicals in the brain that signal pain.

In addition, the brain’s pain receptors seem to develop a sort of memory of the pain and become sensitized, meaning they can overreact to painful and nonpainful signals.

There are likely many factors that lead to these changes, including:

• Genetics. Because fibromyalgia tends to run in families, there may be certain genetic mutations that may make you more susceptible to developing the disorder.
• Infections. Some illnesses appear to trigger or aggravate fibromyalgia.
• Physical or emotional events. Fibromyalgia can sometimes be triggered by a physical event, such as a car accident. Prolonged psychological stress may also trigger the condition.

Risk factors

Risk factors for fibromyalgia include:

• Your sex. Fibromyalgia is diagnosed more often in women than in men.
• Family history. You may be more likely to develop fibromyalgia if a parent or sibling also has the condition.
• Other disorders. If you have osteoarthritis, rheumatoid arthritis or lupus, you may be more likely to develop fibromyalgia.

Complications

The pain, fatigue, and poor sleep quality associated with fibromyalgia can interfere with your ability to function at home or on the job. The frustration of dealing with an often-misunderstood condition also can result in depression and health-related anxiety.

Oct. 07, 2020

Muscle Pain: Causes, Symptoms, Treatment, Prevention

Overview

What is muscle pain?

Muscle pain, or myalgia, is a sign of an injury, infection, disease or other health problem. You may feel a deep, steady ache or random sharp pains. Some people have muscle pain all over, while others have it in specific areas. Everyone experiences muscle pain differently.

Who might get muscle pain?

People of all ages and genders can have sore muscles. When you try a new physical activity or switch up your exercise routine, you may experience delayed-onset muscle soreness (DOMS). Muscle aches may come on six to 12 hours after a workout and last up to 48 hours. You feel pain as the muscles heal and get stronger.

What other symptoms may occur with muscle pain?

In addition to muscle pain, you may also have:

Possible Causes

What causes muscle pain?

Many things can cause muscle pain, including:

• Autoimmune diseases.
• Infections.
• Injuries.
• Medications.
• Neuromuscular disorders.

What autoimmune diseases cause muscle pain?

Autoimmune diseases occur when the body’s immune system mistakenly attacks itself. A healthy immune system fights off germs and infections.

Autoimmune diseases that cause muscle pain include:

What types of infections cause muscle pain?

Bacterial and viral infections can make you feel achy all over. Depending on the cause, you may also have swollen lymph nodes, fever and nausea.

Types of infections that cause muscle aches include:

What types of injuries cause muscle pain?

When you repeatedly use the same muscles at work or during exercise, you may develop sore muscles from overuse.

Other types of injuries that cause sore muscles include:

What medications cause muscle pain?

Certain medications and therapies can cause temporary or chronic pain. Some medicines cause inflammation around muscle cells (myositis) or activate muscle pain receptors. These treatments include:

What neuromuscular disorders cause muscle pain?

Neuromuscular disorders affect muscles and the nerves that control them. They can cause muscle weakness and pain. These conditions include:

What other conditions cause muscle pain?

Other conditions that also cause muscle pain include:

Care and Treatment

How do healthcare providers diagnose muscle pain’s cause?

If you don’t know what’s causing muscle pain, or the pain is severe or chronic, your healthcare provider may order tests, such as:

• Blood tests to check enzyme, hormone and electrolyte levels and test for infections.
• MRI or CT scan to look for muscle injury or damage.
• Electromyography to measure electrical activity in nerves and muscles.
• Muscle biopsy to look for muscle tissue changes that may indicate neuromuscular diseases.

How is muscle pain managed or treated?

Depending on the cause, these steps may help you feel better:

• Rest and elevate the painful area.
• Alternate between ice packs to reduce inflammation and heat to improve blood flow.
• Soak in a warm bath with Epsom salts or take a warm shower.
• Take over-the-counter pain relievers (aspirin, acetaminophen, ibuprofen, naproxen).
• Try complementary therapies, such as massage, meditation or acupuncture.

When to Call the Doctor

When should I call the doctor?

You should call your healthcare provider if you experience:

• Chest pain.
• Fever.
• Loss of bladder control.
• Muscle weakness.
• New or worsening pain.
• Numbness or tingling in limbs.

A note from Cleveland Clinic

Almost everyone has muscle aches and pains now and then. For temporary muscle pain, rest, stretching and pain medicines can help. Chronic or severe muscle pain makes it difficult to do the things you love. If you have a condition that causes chronic muscle pain, talk to your healthcare provider about therapies that can help.

Things You Only Understand If You Have Chronic Pain

If you’re reading this, you likely already know that there is a large — but largely silent — problem of chronic pain in America. One in five adults is living with chronic pain and it is one of the top reasons people seek medical care, according to a 2018 report from the U.S. Centers for Disease Control and Prevention. The impact is immense. Chronic pain impacts nearly every facet of daily life and has been linked to disability, dependence on opioids, higher rates of anxiety and depression, and a reduced quality of life overall, according to the CDC.

Yet many people, including those suffering, are surprised by these stats. Why? Chronic pain is not something people like to talk about much — and those in pain are often encouraged to “suck it up” or “put on a happy face.”

Even worse, there is a lot of misunderstanding around chronic pain. For one thing, chronic pain is not the same as acute pain. Explaining it to someone who’s never had to deal with it can be, well, painful.

“People believe that they ‘understand chronic pain’ because they have also felt pain but it’s a completely different thing when it’s day in and day out for years,” says Monica C., 36, of Phoenix, Arizona, who has fibromyalgia and chronic fatigue syndrome. “I tell people it’s like lifting a glass — anyone can do it for a while — but try to hold a glass in the air for days at a time and you start to get an idea of what I’m dealing with.”

Sound familiar? Then you’ll relate to what these people with chronic pain are saying.

For more information on what causes pain to become chronic and how to treat chronic pain using science-based strategies, visit our Pain, Explained project. You can watch an informative webinar and sign up for a six-part series that dives deeper into chronic pain management strategies. Learn more and sign up here.

Looking fine doesn’t mean we are fine

Remember the old adage not to judge a book by its cover? Well it takes on a new twist in people with chronic illnesses. “On the outside I look normal and fine but trust me, I’m still in pain,” says Cheri G., 50, of Boulder County, Colorado, who lives with chronic migraine, fibromyalgia, and impinged nerves in her spine. “No one understands how much effort it takes to function at all, much less ‘normally,’ in spite of the pain. I look fine. But I’m not fine.”

We need the accessible parking spot but are afraid to use it

Having an invisible disability like chronic pain means that you still need accommodations like anyone else with a disability but you worry about being judged — or worse — when you use them. “My diseases make me disabled, but I get so many negative looks when I put my handicap placard up,” says Mary R., 56, of Columbus, Ohio, who has chronic kidney disease, arthritis, primary hyperparathyroidism, and diverticulitis. “I am in constant, sharp pain; I’ve never been a person who cries easily, but I’m in tears after walking several blocks anymore. Pain isn’t visible.” Learn more here about getting an accessible parking placard when you have chronic pain.

We’re not lazy, we’re exhausted

When doing even the smallest task takes monumental effort, it’s hard to get a lot done in the day. To others, this can look like laziness. “I am many things but lazy isn’t one of them,” Cheri says. “Sometimes I feel like I should try harder to do more but just dealing with the pain takes a lot out of you. It’s exhausting.”

Our side effects have side effects

Back and neck injuries sustained from a car accident have left Anica H., 29, of Burnsville, Minnesota, in daily pain, but that’s just the beginning of the problem, she says. “Because of my injuries I’m in constant pain and the pain means I can’t do as much physically, which has caused me to gain more weight than I’m used to, which in turn has caused my self-esteem to suffer, and from there my relationships have suffered,” she explains. Add in side effects from medications and treatments that then require their own treatments and sometimes it can seem like anything you do causes a cascade of new issues, she adds.

If we have to hear ‘Have you tried…?’ one more time, we’re going to lose it

Tell someone you have chronic pain and a common response is to ask if you’ve tried [insert pill, workout, cleanse, program]. “I really wish people would stop telling me that it will get better with exercise, herbs, meds, diet, or whatever the popular advice of the moment is,” says Alison M., 56, of Dansville, New York, who has rheumatoid arthritis and degenerative disc disease. “Believe me, I have done everything in my power to get healthy, but the fact is that I will always have this disease, there is no cure.”

Guilt is our constant companion

Having chronic pain can bring up a lot of painful emotions along with physical pain — and a major one for many people with a chronic condition is guilt. “I see what I think I should be, especially as a mom, and feel guilty that I’m not that person,” Cheri says. “I feel guilty when I eat. I feel guilty when I sit. I feel guilty when I nap.” Yet all those things are necessary for your health, which can turn into a vicious cycle of negative thoughts and pain.

Our pain sometimes manifests as grouchiness

People often curse when they stub their toe or yell when they touch a hot pan, so it shouldn’t come as a surprise that chronic pain can also appear as anger. Yet all too often people with chronic pain are told that they need to be patient, cheerful martyrs. “Forget that,” says Kristen M., 45, of Knoxville, Tennessee, who has chronic migraine. “I’m grouchy because I’m sick of hurting all the time.”

Our kids have to grow up faster than other kids

It can be difficult to ask for and accept help, especially if it feels like you’re leaning on people that you feel like you should be taking care of. “From the time my kids were young, I had to teach them how to take care of me on my bad days,” says April O., 40, of Mesa, Arizona, who has endometriosis, interstitial cystitis, and fibromyalgia. But while you may feel bad that your kids aren’t having a “normal” childhood, know that they love you and want to help, plus they are learning valuable skills. “Because of this, my kids learned how to cook big, delicious family dinners at a very young age,” she adds. (Here’s one mom’s take on how her rheumatoid arthritis affects her son.)

We consider our pharmacist a friend

Medications aren’t the only way to manage pain but they are often an integral part of your treatment plan — and this means you’re often on a first-name basis with your local pharmacist. This isn’t a bad thing as they understand your chronic pain condition and what you have to do to deal with it better than almost anyone else. “I’ve just had to accept that there will be medication in my life forever,” says Amy H., 34, Dallas, Texas, who has adult-onset asthma.

Pain changes everything in our lives

People without chronic pain can’t begin to imagine all the subtle and surprising ways that it impacts daily life. “There isn’t a single aspect of my life that chronic pain hasn’t changed,” Amy says. “It’s not just my physical health; everything from the importance of the weather forecast to my workouts to my household chores to my mental health is affected.”

We get treated like drug addicts

The topic of opioid medication for treating chronic pain is complicated. Dependency is a real concern, but so is undertreated pain. “I was on [opiods] every day for years and I hated it but I couldn’t function without it,” says Karl H., 66, of Madison, Wisconsin, who has osteoarthritis and ankylosing spondylitis. Then the opioid epidemic hit his midwestern town hard and suddenly pain pills were prescribed far less and anyone who asked for them was seen with suspicion, he says. “I feel like a criminal every time I bring it up with my doctor and they make me jump through so many hoops at the pharmacy. I even had the cops called on me at the ER. I only ever took them exactly as prescribed and they still cut me off,” he says.

Pain management is a lifestyle, not a pill

“Whenever I tell someone about my chronic pain they always ask if I want an ibuprofen. I wish I did. OTC pain meds don’t even touch my pain,” Karl says. Since mostly going off prescription pain pills, he says that he’s had to develop a complex daily pain management routine. “I have to watch every single thing I eat, do the right kind of exercise but not too much, make sure I can get at least 10 hours of sleep, meditate, go to physical therapy, wear my compression gear, stand up and sit down correctly… I could go on,” he explains. “And none of it is optional. If I miss anything, I risk being in so much pain I can’t function.”

We know every bathroom in a 10-mile radius

Regardless of the source of your pain, bathrooms are often the go-to escape route for people with chronic illnesses — they are usually quiet, private, and have some tools that are useful for dealing with surprise pain flare-ups or other symptoms. This means you’re super familiar with the bathrooms in and near every place you go. “I have Crohn’s disease and at times I have diarrhea more than 20 times a day. That’s a lot of bathroom time,” says Kaid G., 60, of Denver, Colorado, who also has osteoarthritis.

We live in constant fear of what’s next

Looking toward the future feels different for people with chronic pain because often they’re terrified of what their disease will do next or what side effects will pop up. “I am constantly so scared about another flare-up,” Kaid says. “The last surgeon that operated on me said if I ever need another surgery, I will need a colostomy bag and that thought is horrifying.”

‘We don’t know’ is the story of our life

There is still so much that the medical community doesn’t know about chronic pain, what causes it, and how best to treat it — and no one understands that better than the patients themselves, Kaid says. “It was 20 years before I finally got diagnosed. No one knew what I had or how to treat it. I felt like a guinea pig,” she says. “And even though I have a name for it now, they still have no idea what causes it or how best to fix it.”

The big stuff hurts, but it’s the little things that break our hearts

“All of my surgeries hurt but what really kills me is I will never be able to do things like curl my hair, lift my grandkids, vacuum a carpet, lift a gallon of milk, type on a keyboard, or even unhook my own bra,” Kaid says. “I feel like I’m not a whole person. I feel like I was robbed of having a normal life.”

We can do everything right and still have it all go wrong

Nothing is more frustrating than finally figuring out what helps you manage your pain only to have it suddenly stop working. “Most of the time I’m totally fine. It’s taken a long time but I manage it entirely with exercise, diet, and stress management,” says Suzi F., 38, of Nova Scotia, Canada, who has fibromyalgia. “But sometimes a flare up will hit me out of nowhere, for no reason, and I go from being fine to being useless in no time at all.”

Pain affects our brains

Pain hurts, yes, but it can also cause cognitive issues, including an inability to focus, mental exhaustion, andbrain fog. “Honestly it’s the mental part that is harder to deal with than the physical,” Suzi says. “I’ve become used to continuing on with my life even when in physical pain, but when my whole head feels foggy and I can’t focus — that is harder to ignore.”

We’ve been accused of faking it

Chronic pain is an invisible disability. For many people, if they can’t see it, “it doesn’t exist.” “I really do a good job of hiding my pain and so sometimes people think I’m making it up or faking my illness, especially when I say I can’t do something because I don’t feel up to it,” Suzi says. This attitude can be particularly painful when coming from loved ones who should know better.

We get so desperate to stop the pain that we’ll try anything

Marijuana was never really something Jen S., of Portland, Oregon, considered using — that is, until she wound up with chronic neck pain after a car accident. Surgery and physical therapy didn’t fix the issue and she didn’t like taking opioids so, at 42 years old, she found herself eating her very first pot brownie. “It helped so much that I got rid of my other meds and now I make my own edibles every month,” she says. Chronic pain makes you reconsider everything. If there’s a chance it will help and the risk of harm is low, it may be worth giving it a shot even if it seems really strange or out there, she adds.

We’ve lied about our pain to make someone else feel better

You’re already in pain so why spread it to your loved ones by making them upset too, right? “Sometimes it’s just easier on everyone else to pretend like I am fine, even if my pain is awful,” says Mary S., 42, of Lodi, California, who has post-chemo neuropathy. “There are only a handful of people in my life who I can be honest with and those few are chosen because they know I don’t want to be a drama queen.”

We’ve been blamed for our own pain

One way for people to deal with the scary uncertainty of your chronic pain is to convince themselves that you must have done something wrong to deserve it. “I have left so many conversations with people — whom I don’t know well — emotionally exhausted and in tears because of their assumptions that if I wanted to be better I could,” Mary says. “They assume I won’t see a doctor or that I’m refusing to do things to make my life better.”

Our pain tolerance is super-human

Some people think that being in constant pain is a weakness — that you’re not tough enough — but the reality is the opposite, says Eric L., 34, of Houston, Texas, who has psoriatic arthritis and chronic fatigue syndrome. “I can’t tell you how often I’ve been told to ‘just man up’ and ‘it’s just a rash,’” he explains. “The thing is I’ve got an incredibly high tolerance to pain, much higher than I used to. I can function every day with levels of pain that I couldn’t have even imagined before.”

A doughnut is never just a doughnut

Explaining your limitations to people and getting them to believe and respect them can be exhausting, Eric says. “Gluten makes my symptoms flare. Yes, I’m sure. No, it’s not a fad diet. If I eat that doughnut at my morning meeting, I won’t be able to walk later,” he says.

‘Scary’ side effects don’t rule out a medication

Living with chronic pain with no respite and no end in sight can sometimes feel like a death sentence, so when you’re offered medication that might help, even if it has potentially scary-sounding side effects, you still consider it, says Elizabeth P., 36, Ridgecrest, California, who has rheumatoid arthritis.

We’ve spent an entire party lying in the spare room in the dark

Your pain doesn’t care if it’s your 40th birthday party or the first Thanksgiving dinner with your whole family in a decade or your baby’s first steps — it can still totally crash the party.  “One of the things that causes me the most anxiety is realizing how much life I’m missing out on because I have to lie in a dark, quiet room,” says Jennie B., 41, of Minneapolis, Minnesota, who has migraine disease.

We laugh when people ask when we’re going to get better

Chronic pain is unfortunately very often a permanent condition. “Most people forget that I’m not going to get better and my limitations are a permanent part of my life,” says Jennifer A., 48, of Gilbert, Arizona, who has rheumatoid arthritis, fibromyalgia, postural orthostatic tachycardia syndrome (POTS), and chronic fatigue syndrome. “They expect to see ‘progress’ and when it doesn’t happen it makes me feel like a failure because I can’t get better. I just manage what I’ve got and take whatever good or lousy day comes.”

Not Sure What’s Causing Your Pain?

Check out PainSpot, our pain locator tool. Answer a few simple questions about what hurts and discover possible conditions that could be causing it. Start your PainSpot quiz.

What If You Hurt ALL the Time?

“I hurt terribly all the time and nothing helps!” If you relate to this, or hear this from someone in your personal life or professional practice, it can feel depressing, discouraging, and trigger feelings of hopelessness. Yet even when pain is severe and unrelenting, everybody experiences some variation. It may be that:

• Hot soaks or other types of soothing rest breaks may cause aches and pains to recede.
• Creative endeavors or other distracting activity may cause pain to take a back seat.
• An amusing movie or an enjoyable interchange may cause burning or shooting pain to become less evident.

Such reprieves may seem inconsequential because they are time-limited and the degree of relief is minimal. They will not help people feel “pain-free” or able to behave or feel “as before.” But any variation can be mined for answers that lead to positive adaptations. Learning the reasons for ups and downs can enable increased control and comfort.

Of course, severe pain can make variation difficult to spot. Pain and accompanying depression both tax cognitive abilities. Thus, people who live with chronic pain are more vulnerable to negative thinking, such as “it’s always this bad!” and to compromised memory, which make fluctuations more challenging to recall or view in context.

So what can you do if you can’t locate variation in your experience? What if it feels like your pain is a constant 10 out of 10?

Notice your worst times.

One strategy is to consider times that felt even worse. This has been a helpful first step for clients of mine who felt that their pain was “always the same.” No matter how bad it may be; it can always get worse. (I know this, too, from personal experience!) If you are struggling to recall any moments of relief, start by looking for the opposite. Exploring the reasons for worst moments reveals clues about ways to reduce their frequency and duration. You might notice that your pain was particularly difficult when:

• Barometric pressure rose with a coming storm,
• You stood in a long line, embarked on a jam-packed day, or stayed in bed for days, and/or
• You received unpleasant news or had been mulling over an unpleasant thought.

Factors associated with intensified symptoms can provide clues to antidotes or alternatives.

Process of understanding:

Once you identify when your symptoms were at their worst, dig into the detail. If your pain spikes during times of high stress, you might practice relaxation techniques, such as diaphragmatic breathing and meditation. If sleep interruption is to blame, you might focus on sleep-enhancing tricks. Even identifying factors that are beyond your control can be useful. Take the weather, for example. Many people find heavy atmospheric pressure intensifies symptoms. While we cannot change the weather, we can adapt our response to it. Don’t underestimate the power of being able to say to yourself, “it makes sense that my pain is higher today” instead of feeling blindsided by an unexpected painful flare. Awareness of exacerbating factors can let you plan your schedule accordingly and reduce overgeneralizations that intensify suffering. At times not making things worse is the best anyone can do. Moreover, you can treat relevant information—such as the coming of a high-pressure weather front—as a cue to be ready with your most soothing, compassionate responses.

Silver lining:

Identifying times when your pain was worse also means there are times that were “less bad.” This reveals positive variation that might have otherwise been missed when thinking is overwhelmed by exhaustion. Recognizing variation, even subtle movement, introduces the possibility that you can understand and affect your experience.

Among the struggles of chronic pain is unpredictability. Flare-ups that seem out of the blue not only make it impossible to make plans but can make people feel powerless and demoralized. As you observe your ups and downs and the factors associated them, you gain control. This may come little by little. Figuring out how to reduce pain from a 10 to a 9 may not seem significant; but, as you learn what helps, you can incorporate this into your life, leading to greater and lasting improvement.

Be mindful of variation.

Mindful attention to variation itself can reduce suffering. Mindfulness involves deliberate awareness to the present moment, without judgment. Mindfulness reveals difficult moments for the moments they are, without assigning them undue significance, and emphasizes the choice we have in each and every moment. It can be helpful to remember that all we ever have to survive is this current moment. Approaching any feelings, thoughts, or sensations that arise as transitory can help you through them. When phrases like “I can’t take it” arise in your day, practice viewing them as fleeting thoughts rather than facts. Such thoughts may come and go but do not define your whole reality. Awareness of variation can not only reduce the sting of low points, but open us to see the positive exceptions.

Adopt a curious mindset.

Variation represents possibility. Research shows that perception of chronic pain and fatigue depends on a long list of factors including how we breathe; medication; engagement in positive distractions; emotional and physical intimacy; pacing of activity and rest; application of heat and cold; laughter; gradual and graduated exercise; our facial expression, self-talk, and attitude. As you note what brings relief, build these into your day and see the effects add up. By learning what helps (and hurts), you can make informed choices to increase joy, capabilities, and comfort.

What gets in the way?

The strategy may feel inadequate when you are wracked with pain and nothing brings sufficient relief. But what is the alternative?

Sometimes judgments about what “should be” interfere with steps to adapt, adjust, and embrace life as it is, in the best way you can. This is understandable; however, fighting against one’s current reality worsens the experience. Consider the example of standing in a long line or another activity that likely increases pain. While in line, you can intensify your suffering by fighting against reality with statements like, “this shouldn’t be so hard!” Or, you can bring a folding chair, stretch, meditate, engage in conversation, slow your breathing, or any number of strategies to reduce discomfort, while planning a restorative break to follow.

Acceptance does not mean liking things as they are. Chronic illness is dreadful, incredibly challenging, and involves multiple losses. You may have times when you need to wallow in the misery. Be gentle with yourself. Grief is an important part of this process. Make sure to acknowledge the validity of this.

Hope is vital!

Sometimes people with chronic pain retreat out of hopelessness. Looking for the variation in one’s experience—no matter how trivial it may seem—can be a vital first step in enhancing the life that you have.

© 2013 Deborah Barrett

Author, Paintracking: Your Personal Guide to Living Well with Chronic Pain

For more on this approach, including a free online tracking tool, please visit: www.paintracking.com

You can also join me on Facebook

Where the Body Meets the Brain

Trans Am Clin Climatol Assoc. 2015; 126: 167–183.

Leslie J. Crofford

Nashville, Tennessee

Leslie J. Crofford, Nashville, Tennessee;

Correspondence and reprint requests: Leslie J. Crofford, MD,
1161 21^st Ave S., MCN T-3113, Nashville, TN 37232, Phone: 615-322-4746, Fax: 615-322-6248, [email protected] © 2015 The American Clinical and Climatological AssociationThis article has been cited by other articles in PMC.

Abstract

Chronic musculoskeletal pain is one of the most intractable clinical problems faced by clinicians and can be devastating for patients. Central pain amplification is perceived pain that cannot be fully explained on the basis of somatic or neuropathic processes and is due to physiologic alterations in pain transmission or descending pain modulatory pathways. In any individual, central pain amplification may complicate nociceptive or neuropathic pain. Furthermore, patients with somatic symptom disorders may have alterations in their psychological or behavioral responses to pain that contribute significantly to the clinical presentation. Genetic, physiologic, and psychological factors associated with central pain amplification are beginning to be understood. One important contributor to chronic pain is perceived stress and stress response systems. We and others have shown a complex relationship between the physiologic stress response and chronic pain symptoms. Unfortunately, treatments for chronic pain are woefully inadequate and often worsen clinical outcomes. Developing new treatment strategies for patients with chronic pain is of utmost urgency. This essay provides a framework for thinking about chronic pain and developing new treatment approaches.

INTRODUCTION

Perhaps no other symptom induces such fear and loathing as chronic pain. Most images of pain are focused on portraying negative emotions and the intrusive nature of the pain experience (). Clinicians as people fear chronic pain, a symptom that demands attention and intrudes into every aspect of a person’s life. Clinicians also loathe chronic pain, perhaps the symptom that brings more patients into our practices than any other but also the symptom most likely to make us feel helpless as healers.

The International Association for the Study of Pain defines it as “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage” (1). Pain is always subjective in that each individual learns the application of the word through their own experiences. Biologists recognize that those stimuli which cause pain are liable to damage tissue. Accordingly, pain is that experience we associate with actual or potential tissue damage. It is unquestionably a sensation in a part or parts of the body, but it is also always unpleasant and therefore a negative emotional experience. Many people report pain in the absence of tissue damage or any likely pathophysiological cause, and there is usually no way to distinguish their experience from that due to tissue damage. Thus pain has several important dimensions: a sensory dimension — where does it hurt and how much does it hurt; an emotional dimension — how unpleasant is the experience; and a cognitive dimension — how do we interpret the pain based on our previous experience, does it cause fear and anxiety, and how do we respond to the threat posed by pain. Any given individual could report a pain experience that is not easily understood by the clinician they encounter and to whom they turn for explanations and relief. Further, there is no distinct boundary between normalcy and disease. Most of us transiently experience pain symptoms. Many of us have chronic symptoms that do not rise to a level that interferes with function. The transition from normal to sick is a quantitative deviation that involves both primary (biologic) and secondary (psychological, social, and cultural) risk factors.

CLASSIFICATION OF CHRONIC PAIN

Acute pain is likely to arise through tissue damage, termed nociceptive pain or “pain that arises from actual or threatened damage to non-neural tissue and is due to the activation of nociceptors.” That is, a signal is generated from abnormal peripheral tissues and transmitted by the dorsal horn pain transmission neurons to the regions of the brain that receive this input. Neuropathic pain is “pain caused by a lesion or disease of the somatosensory nervous system.” This requires a demonstrable lesion (seen on imaging, neurophysiology tests, biopsy results, laboratory testing) or a disease (stroke, vasculitis, diabetes, shingles) that satisfies established diagnostic investigations. Many times, however, the extent or intensity of the pain complaint cannot be easily explained by histological, anatomical, or biochemical processes. In these situations, we may invoke central amplification of pain or centrally maintained pain (2,3). The physiology of central amplification of pain is only now becoming understood, thanks in large part to advances in imaging (4).

Chronic pain is usually defined as pain lasting more than 3 months and almost certainly has some, albeit variable, element of central sensitization. However, any mechanistic combination — nociceptive, neuropathic, and central — may be present in a given individual. Chronic pain is a complex sensory and emotional experience that varies widely between people depending on the context and meaning of the pain and the psychological state of the person (5). Cognitive and emotional factors have a critically important influence on pain perception and these relationships lie in the connectivity of brain regions controlling pain perception, attention or expectation, and emotional states. Imaging studies have confirmed that activity of afferent and descending pain pathways are altered by attentional state, positive emotions, and negative emotions among many other factors unrelated to the pain stimulus itself. The physiology of central pain amplification at the level of the brain takes into account these important connections. There are now numerous studies that demonstrate that patients with chronic pain have alterations in brain regions involved in cognitive and emotional modulation of pain (5). This complex interplay may explain why patients with long-term chronic pain develop anxiety and depression, but also why those with cognitive distortion and psychological distress are at increased risk for chronic pain and central amplification of pain.

Chronic regional pain is present in 20% to 25% of the population and chronic widespread pain is present in approximately 10% of the population (6). Those patients with one pain condition are more likely to develop another, more centralized form of pain. For example, patients with inflammatory or degenerative joint disease, for example, are almost four times as likely to also have fibromyalgia, the prototypical musculoskeletal central pain amplification syndrome (7). Centrally maintained pain, in contrast to nociceptive or neuropathic pain, is usually multifocal, difficult to precisely localize, moves from site to site, and may have variable pain descriptions.

Chronic pain syndromes, such as chronic headaches, temporomandibular disorder, fibromyalgia, irritable bowel syndrome (IBS), interstitial cystitis/irritable bladder, pelvic pain, and others, cluster together in an individual (8) (). Often times, chronic pain syndromes wax and wane over time with one or the other dominant at a given point in time. It is not unusual, for example, for a patient to have a visceral pain syndrome, such as IBS dominate the overall symptom profile for a time then recede as fibromyalgia symptoms become more prominent. Chronic pain also clusters with other somatic symptoms including fatigue, unrefreshing sleep, dyscognition, and mood disturbances. We have shown alterations in sleep (9–11) and cognitive function (12,13) in patients with fibromyalgia. Other clinical syndromes, such as chronic fatigue syndrome/myalgic encephalomyelitis, have musculoskeletal pain as part of the diagnostic features. This leads to the frequent presence of multiple diagnoses and multiple providers interacting with a given patient, potentially leading to multiple testing that may increase anxiety and multiple drug treatments that may interact or cause adverse effects.

BODY AND BRAIN: A HISTORICAL VIEW OF THE CHRONIC PAIN EXPERIENCE

There is much in the medical literature regarding the interplay between musculoskeletal pain and psychological distress, although only a few of these will be discussed. One starting point is the description of “psychogenic rheumatism” where one of the earliest case series was recorded in 1946 by Nobel Laureate Philip S. Hench and Edward W. Boland as they describe the characteristics of US Army veterans returning from war (14). Psychogenic rheumatism was one of the more common diagnoses, affecting approximately 20% of patients in specialized rheumatic disease centers. According to their report, “Psychogenic rheumatism — the musculo-skeletal expression of functional disorders, tension states, or psychoneurosis — is one of the commonest causes of generalized or localized aches and pains in muscles and/or joints in either civilian or military life.” They identify that this condition may occur either alone, or as an overlay to rheumatoid arthritis or fibrositis, their term for soft tissue rheumatic disorders such as bursitis or tendonitis. They went on to describe that primary fibrositis “puts its victims at the mercy of changes in external environment: thus weather, heat, cold, humidity, rest, exercise, etc. characteristically influences most of them for better or for worse.” On the other hand, psychogenic rheumatism “puts its victims at the mercy of changes in the internal environment: thus their symptoms may vary with mood or psyche, pleasure, excitement, mental distraction, worry, or fatigue.” The description of psychogenic rheumatism included an attitude that was tense, anxious, defensive, and antagonistic. The chief symptoms were described as burning, tightness, weakness, numbness, tingling, queer or tired sensations that were often continuous day and night. They also describe severe fatigue causing disability, worsening of symptoms during and after exercise, and a “touch me not” reaction to examination.

Arthur J. Barsky and Jonathan F. Borus describe “functional somatic syndromes” characterized by higher levels of symptoms, suffering, and disability than by consistently demonstrable tissue abnormality (15). These authors indicate that the symptoms common to the functional somatic syndromes include fatigue, weakness, sleep difficulties, headaches, muscle aches and joint pain, problems with memory, attention, and concentration, nausea and other gastrointestinal symptoms, anxiety, depression, irritability, palpitations and racing heart, shortness of breath, dizziness or light-headedness, sore throat and dry mouth are highly prevalent in the population in general. Furthermore, patients often meet the criteria for other syndromes in part because of the overlap in diagnostic criteria. In their analysis, these authors implicate “four psychosocial factors that propel symptom amplification including the belief that one has a serious disease, the expectation that one’s condition is likely to worsen, the sick role including the effects of litigation and compensation, and the alarming portrayal of the condition as catastrophic and disabling” (15). The biological process of selecting sensations believed to have pathological significance for conscious attention lies in the realm of cognitions around these sensations and, certainly, pain is a symptom often selected for significance. There is also often an influence of negative memory of past symptoms and expectations of future symptoms that may play a role in the cognitive amplification processes.

More recently, Frederick Wolfe has been a proponent of the term “polysymptomatic distress” that incorporates multifocal musculoskeletal pain and neuropsychological symptoms of fatigue, unrefreshing sleep, dyscognition, and other functional somatic syndromes into a quantitative scale that allows for a flexible and continuous application in patients with any rheumatic disease and in the general population. It is clear from his work that individuals can have a variable degree of polysymptomatic distress that influences clinical outcomes no matter what other diagnoses may be present (16).

The American Psychiatric Association in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has replaced the previous categories of somatoform disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder with “somatic symptom disorder (SSD) with predominately somatic complaints” and “SSD with pain features” (17). This diagnosis is characterized by “distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms.” Importantly, the previous requirement that symptoms had to be medically unexplained is removed and psychological symptoms surrounding the somatic symptoms have been added. These include excessive thoughts, feelings, or behaviors related to somatic symptoms or associated health concerns as manifested by rumination and/or high level of anxiety about health or symptoms and/or excessive time and energy devoted to symptoms or health concerns.

In all these ways of thinking about chronic pain and its associated multiple somatic symptoms, there is an underlying theme of the inability to objectively verify the symptoms expressed by the patient (). Most of these frameworks explicitly indicate that chronic pain is associated with abnormal ways of perceiving and reacting to sensory information. Precisely because of the inherent subjectivity of the symptoms and the observation that the symptoms are amplified beyond what is viewed as “normal,” the clinician is placed into a situation that requires a judgment about the veracity of patient reports. This most uncomfortable position is augmented because the treatments available for chronic pain, particularly the use of opioid analgesics, are not effective and can be addictive, misused, abused, and diverted (18).

GENETIC RISK AND ENVIRONMENTAL TRIGGERS FOR CHRONIC PAIN

An individual’s risk for developing central pain amplification might be predicted by a personal or family history of chronic pain and, by virtue of shared genetic risk factors, anxiety and depression. Enormous strides have been made in the understanding of the genetics of pain. Pain sensitivity is strongly genetic in that it differs within inbred mice and rats and strongly runs in families in humans (19). Pain sensitivity, or the response to acute psychophysical testing, is present in a Bell shaped curve in the normal population (20).

A number of genes, including such genes as ion channels and genes in the monoamine metabolic pathway, are associated with pain sensitivity and there is imperfect overlap between these genes and chronic pain conditions. This may be related to the multiple overlapping pathways between pain and psychological responses to pain. For example, two major neurotransmitter pathways have been repeatedly associated with musculoskeletal pain (19). The first is the adrenergic pathway, in which COMT, the gene encoding the enzyme catechol O-methyltransferase that is responsible for the catabolism of catechol neurotransmitters such as epinephrine, norepinephrine, and dopamine, is the most frequently associated with chronic musculoskeletal pain conditions. Most studies of COMT report an increased risk of chronic pain associated with a Val159Met (rs4680) that encodes a protein with lower enzymatic activity (19). More extensive studies have expanded the functional locus to three major haplotypes that modify expression and activity of the enzyme thus conferring low- and high-risk phenotypes for acute pain sensitivity as well as risk for developing chronic pain (20). Additional genetic variation in the β₂-adrenergic receptor gene (ARDRB2; rs1042713 and rs1042714) has been associated with an increased risk of fibromyalgia and chronic widespread pain. Haplotype variants that regulate β₂-adrenergic receptor expression and internalization are associated with differences in susceptibility to chronic pain (21). The second pathway associated with chronic pain syndromes is the serotonin pathway. Specific genes include the 5-hydroxytryptamin receptor 2A (HTR2A) and 5HT transporter (SLC6A4) (22–24). A 44-base pair insertion/deletion polymorphism in the promoter region of SLC6A4 is most frequently associated with risk of chronic pain conditions (19). These genetic pathways are associated with “endophenotypes” or intermediate measurable phenotypes that are present in patients with chronic pain. These include autonomic dysregulation, altered pain processing and modulation, sleep dysfunction, and anxiety in the case of the adrenergic pathway (19). Personality and affective traits such as somatic awareness, depression, and anxiety have been associated with genetic variation in the serotonin pathway and are associated with risk for chronic pain (19).

It is quite clear that experiences or environmental triggers can be the proximate cause of chronic pain (that is, acute pain can transition to chronic pain). One interesting example is that of post-infectious IBS. Risk factors for developing IBS following infectious enteritis (which occurred in 15% of affected individuals) were female sex, younger age, prior anxiety/depression, and fever or weight loss during the acute enteric illness (25). However, even in this example in which a clear triggering event can be studied in a population, psychosocial factors are important risks. A history of childhood stress and current psychosocial stress increases the risk for developing chronic centrally maintained pain (26). In many longitudinal epidemiologic studies, chronic pain and other somatic symptoms can be predicted by childhood abuse and traumas, low educational attainment, social isolation, depression and anxiety (27) (). In a population-based study to determine psychosocial factors that predicted new-onset chronic widespread pain, investigators identified a random sample of subjects from socio-demographically disparate backgrounds then identified more than 3,000 who did not have pain at baseline and more than 300 that had new widespread musculoskeletal pain at follow-up examination (26). The strongest predictors were premorbid somatic symptoms, illness behaviors, and sleep problems. In another community-based study, perceived physical and emotional trauma as precipitating factors for fibromyalgia were associated with health-care seeking rather than pain severity (28). One can speculate both intrinsic factors and learning around the affected organ as important for the maintenance of symptoms. The biopsychosocial model of pain posits that pain experience and its impact of the individual is a function of interacting combinations of nociceptive input; psychological processes including beliefs, coping repertoire and mood; and environmental contingencies that would include family, community, and cultural rules or expectations (29). All of these factors are likely to play a key role on the clinical expression and health impact of chronic pain.

STRESS, AROUSAL, AND CHRONIC PAIN

Because development of centrally mediated chronic pain is associated with stressful events and symptoms often wax and wane depending on perceived stress, there have been many studies focused on stress and stress response systems in patients with these syndromes. Our original studies focused on the hypothalamic-pituitary-adrenal axis (HPA) in chronic pain and fatigue and we have demonstrated alterations in the dynamic function of this system (30,31). Because of the dynamic nature of stress and response, we have spent considerable effort modeling the function of the system in patients with chronic pain (32,33). We have found that the modeled stress-arousal parameters of HPA axis function may be related to symptom clusters such as fatigue-predominant or pain-predominant. Furthermore, somatic symptoms increase when, during the nocturnal period, cortisol is leaving the system at a faster rate than it is being produced (32). Studies in this realm have been highly variable likely due to the difficulty in defining phenotypes and comorbidities that may dramatically influence the physiology of the stress-arousal system.

We have also investigated the function of the autonomic nervous system (ANS) as affecting sleep and fatigue. Many investigators have discussed alterations in the sympathetic nervous system in patients with fibromyalgia and chronic fatigue syndrome (34). We found similar alterations in heart rate variability and also found peripheral effects of altered vascular reactivity during exercise that may be related to ANS function (9,35). The two branches of the ANS, however, have antagonistic effects on autonomic arousal. Arousal is under tonic inhibitory control of the parasympathetic branch via the myelinated vagus nerve (termed the “vagal brake” or “parasympathetic maintenance”), which allows for efficient upregulation of arousal via parasympathetic reduction (or “vagal withdrawal”) (36). Parasympathetic maintenance promotes calm engagement, whereas vagal withdrawal facilitates quick escape from danger. Fibromyalgia and temporomandibular disorders are linked to higher baseline sympathetic activity or predominance, especially at night, and lower baseline parasympathetic activity. With regard to ANS reactivity in these disorders, some evidence points toward blunted sympathetic responding coupled with greater increases in arousal, from which one might infer greater parasympathetic reduction in response to the environment. We recently reported an exaggerated parasympathetic decline in a non-threatening situation, which was related to negative physical and psychosocial outcomes (36). This exaggerated response is associated with hypersensitivity to environmental danger and is a marker of emotional lability.

SELF-REGULATION IN CHRONIC PAIN

It is often stated that illness behaviors accompany chronic pain. Successful adaptation to chronic pain conditions may depend on an individual’s ability to self-regulate, that is, ability to exercise control or guide and alter reactions and behaviors. The ability to self-regulate varies across people and situations, and self-regulatory strength appears to be an individual difference and a limited resource that can be fatigued (37). We hypothesized that patients with chronic pain may display adverse health behaviors because chronic pain may deplete this important resource. Experimentally, this can be measured by the ability to persist on a task following a high or low demand self-regulation task. Indeed, we were able to demonstrate experimentally that patients with fibromyalgia and temporomandibular disorder had a deficit in self-regulation that was evident following a low self-regulation task (38). Persistence was also associated with heart rate variability, linking the physiology of the stress response system to an important behavior. Another recent study of patients with fibromyalgia performed a cluster analysis based on pain characteristics and cognitive, affective, and behavioral responses to pain and stress (39). The study demonstrated that psychophysiological responses of blood pressure, heart rate, and skin conductance were associated with specific types of psychological coping and psychiatric diagnoses.

MUSINGS ON THE TREATMENT OF CHRONIC PAIN

When you eliminate 90% of a patient’s pain, the remaining 10% is 100% of what is left. This reminds us that any pain is still pain. Furthermore, when pain becomes chronic, the goal in most cases is management rather than elimination. One of the most distressing recent developments in medicine is the explicit focus on eliminating pain — manifested as pain as the fifth vital sign and relief of pain being used to measure the quality of a health care facility. Of course, relief of acute pain is an important function of health care, but too often there is no thought to the distinctions between acute and chronic pain and the negative outcomes of analgesics used for chronic pain. The institutionalized focus on eliminating pain is concomitant with the increase in use of opioids for chronic non-cancer pain (18,40).

Strategies for treatment of chronic pain include antidepressants that increase synaptic norepinephrine and serotonin, agents that reduce neuronal excitability, and analgesics. Simple analgesics are typically ineffective for centrally maintained pain. Opioids are also typically poorly effective and have many clinical and societal issues that make their use problematic (18). Concerns around opioid-induced hyperalgesia appear in the medical literature as early as 1870 when Clifford Albutt noted that “I have much reason to suspect that reliance on hypodermic morphia only ended in that curious state of perpetuated pain” (41). From a clinical perspective, it is quite difficult to distinguish opioid-induced hyperalgesia from tolerance or merely inadequate analgesia. However, when patients on high-dose opioids continue to have high levels of pain that becomes more diffuse and difficult to localize with persistent treatment, it should trigger concerns. In truth, none of the available pharmacologic treatments for chronic pain are particularly effective and the non-pharmacologic treatments are difficult. Developing new treatment strategies for treatment of chronic pain is of utmost urgency and must start with a better understanding of the pathways that facilitate the transition from acute to chronic pain and maintenance of chronic pain.

Our patients are looking to us for help. When we have students in the clinic or participating in our research programs targeted towards understanding chronic pain and developing treatments, they often ask us how to handle patients with chronic pain — what do we say? It is essential that we understand what we as physicians can do and what is beyond the capabilities of medicine. Above all else, make sure that patients understand that we are hearing them, that we are thoughtfully considering their symptoms to be sure we do not miss a remedial cause of their symptoms, that we care about their suffering, and that we will help them to the best of our ability (). This does not mean that we can make their pain go away. Often the factors that precipitate and maintain chronic pain are beyond the reach of medicine. It also does not mean that we will give them analgesic medications, in large part because these drugs are counterproductive for the patient not to mention the society at large. Providing behavioral guidance is definitely more time consuming than ordering a test or writing a prescription. However, there is no treatment for patients with chronic pain that makes a bigger difference than our empathy and our time.

Footnotes

Potential Conflicts of Interest: None disclosed.

DISCUSSION

Gotto, New York: I wanted to ask you about a form of chronic pain associated with depression. I’ve seen a few patients with depression, and there is a subgroup of patients whom the depressive episodes are associated with severe pain. It’s not characteristically located in any part of the body, but it doesn’t seem to be helped by electroshock therapy. I am wondering if you have any thought about etiology or treatment of this syndrome.

Crofford, Nashville: I don’t have many thoughts about treatment because I don’t think many of them work really well. I do think that it is very likely that patients who have what they call painful depression do have pain etiology that likely originates, in my view, in the fear centers within the central nervous system. These are overlapping; the genes are shared. I think it is incredibly common that — or certainly neurophysiologically feasible — that some of the biochemical etiologies of pain can arise specifically from dysfunction of the central nervous system rather than an anatomical or histological stroke-associated, for example, pain syndrome. But thank you for that question and I think it is a difficult problem.

Palmer, New York: I think it was Dr. Nuland who wrote at one point that pain is ubiquitous but suffering is optional. And we know that people who mark 7 on their pain scale out of 10 vary a lot on how that pain of seven is affecting them. Is there any way of quantitating the suffering or the response of patients to a given pain?

Crofford, Nashville: Well, the best way is to ask the patient. I think that is the crux of the problem. We, as physicians, bring our own understanding to the pain experience when we interact with an individual. It is so easy to look at the patient and say, well I don’t think that that arthritis is bad enough to cause that much pain. But that is the filter in our own brain, and suffering is an intensely personal experience. A lot of it has nothing to do with physiology and has much more to do with that patient’s previous experiences and their cognitive interpretation of the symptoms that they are feeling. So I think the only way that I know to quantitate suffering is to ask the patient and to believe the patient when they tell you how much they are suffering.

Alpert, Tucson: this is a huge problem. In last week’s JAMA you probably saw the editorial that says there are a hundred million Americans suffering chronic pain. That is almost a third of the country. When I attend on inpatient ward medicine, there are lots of patients being admitted, as I am sure you have seen in Nashville. The ER does not want to deal with these patients and they just admit them to medicine. Actually, my diagnosis is a little different from psychiatry literature, that it is psychosocial sexual dysfunction. It is the sum total of all the horrible things that have happened to this person that puts them exactly in the chronic fatigue and chronic pain and constantly seeking, of course, more and more narcotics. Of course that infuriates the house officers, and the whole situation just deteriorates. So that is a comment. I don’t know what the solution is. When I was at University of Massachusetts, there was a young man named Jon Kabat-Zinn who was actually a DNA biophysicist who was a long life meditator. He came to me one day and said, you know, I’d like to try this. I hear that meditation can help with chronic pain. So eventually that led to Jim Dalen, who was the dean then and had a master’s degree in psychology. With his agreement we did an experiment in which he went to the orthopedists and said, “I want you to send me the patients that you hide under the desk from when you see them coming.” They have been operated on multiple times and all they are looking for is narcotics. He put them all through the program and there was a remarkably good response rate. The patients’ remark was, just like the last comment: I still feel the pain, but it doesn’t bother me as much. So it really is the difference between the pain fibers and the suffering.

Crofford, Nashville: I think that is a wonderful comment. I think, you know, we as a medical establishment have almost facilitated this concept that there is a pill for pain. There really isn’t a pill for pain, exactly for the reasons that you point out. The more that we see more commercials on TV saying, if you take this pill you are going to be healed and feel wonderful. But the truth of the matter is that the more that we focus on a drug-based solution for these problems that surely they have something to do with the somatosensory pathways, but I don’t think we are doing our patients a favor but pretending that these patients that have suffering in association with their chronic pain are going to be fixed by a pill.

Alpert, Tucson: Is there anybody doing deep brain stimulation for some of these very severe cases?

Crofford, Nashville: Yeah, there are people that have started looking at that. We had a little bit of conversation at the level of the NIH and whether or not this is something that we want to embark on. The truth of the matter is, as you point out, this is such a common disease that I am not even sure that I am enthusiastic about going there. Again, it gets to the concept that there is a medical answer for chronic pain, and I really don’t think there is a medical answer for this problem. And the more we emphasize it the less likely we are going to address the root causes of the problem.

Zeidel, Boston: With more and more functional imaging and precise deep brain stimulation, you have to believe that a portion of the patients might respond very well to this. I guess the key would be figuring out which patients might have these reinforcing pathways that might be potentially interruptible. Those sorts of stimulations could be much more specific than, for example, narcotics.

Crofford, Nashville: I don’t disagree. I think that you know people that have been looking at the central networks associated with chronic pain in animals as well as in people are finding really interesting differences between chronic pain patients and patients without chronic pain in terms of the degree to which the networks light up, particularly in these very deep amygdala fear centers. I think that is a large part of the issue that we just can’t deal with in the usual ways. Certainly it is an experiment begging to happen. But I do worry about the next wave which is, “Woo! If I could get deep brain stimulation, I can be cured from my chronic pain.”

Zeidel, Boston: It is going to be all about selection.

Crofford, Nashville: Exactly.

Telen, Chapel Hill: I am a hematologist, and I have spent a lot of my life taking care of sickle cell patients, which turns hematologists into pain doctors, especially if they take care of adults. And it’s become clear, I think as you describe, that all those different types of pain are involved in sickle cell pain. It’s very hard when someone comes into the emergency room or the day hospital to decide if this is a vaso-occlusive pain episode or is this exacerbation of chronic pain. Somewhere between 30% and 50% of our population and in a lot of clinics in the United States are on daily opioid medicines, either short-acting or long-acting, or both. A recent study of vaso-occlusive episodes in a phase 2 study with a targeted drug that targeted mechanisms of vaso-occlusion had as its most obvious efficacy endpoint a huge reduction in opioid use, which was patient-controlled analgesia — a doctor had relatively very little to do with it. With this understanding of these multiple types of pain and the fact that they are often all there together, how do you see that really affecting how we deal with chronic pain, especially in patients who clearly have long standing tissue damage like sickle cell patients?

Crofford, Nashville: I think that is a great question. We deal with it often in our patients, for example, with osteoarthritis. There are some patients that have a peripheral pain generator that when you make it go away; even the elements of central pain that they are experiencing get better. So for example, if we have patients with osteoarthritis in the knee, no matter what kind of central elements of pain they have, you take out the old knee and give them a new knee and their pain goes away, and their pain syndrome goes away. But there are others in whom that does not happen. And trying to tease out what are the elements of pain that are peripherally maintained and what are the elements of pain that are centrally maintained is exceptionally challenging. There are a number of people that are working on trying to understand, particularly using psychophysical or functional MRI testing and how you tease that apart. It is not easy.

Wenzel, Richmond: Does acupuncture work? If so, what patients are likely to respond, and do you have an idea of how it might work?

Crofford, Nashville: So, many of our body-based therapies are very difficult to study. The studies that I am most familiar with are in patients with fibromyalgia where at least three or four large acupuncture studies have been done where sham acupuncture works as well as real acupuncture. I do think it works. This gets at the issue of what is placebo and what is the placebo effect, and can you stimulate the central pathways that are associated with how you think about chronic pain, because that does make a difference in the experience of chronic pain. Based on the studies where sham and real acupuncture work, I don’t know if I can specifically tell you a peripheral mechanism for the efficacy of acupuncture. But I can tell that acupuncture works, and I use it in people who want it.

Hochberg, Baltimore: I would like to further comment on and amplify Leslie’s response to Dr. Wenzel’s question. So the studies in osteoarthritis of the knee — which I am familiar with, contributed to, and happen to analyze to a great extent — show that there is a small statistical difference between real acupuncture and sham acupuncture. But there is a large difference between sham acupuncture and standard of care, which in most of the studies involves an educational intervention. What that gets to is the need for practitioners — who take care of patients like Leslie is describing that present with chronic pain and other chronic somatic symptoms — to harness the placebo effect; in the interaction between the clinician and the patient, to listen to the patient, to be empathetic to the patient, and to stress the positives of the interventions which we will pursue as a team going forward. We know that sham acupuncture works a lot better than giving an oral placebo tablet. Injectable placebos work much better than giving an oral placebo tablet. Topical placebos work much better than giving an oral placebo tablet. So everything we do with the patient together as a team works to some extent in terms of improving their symptoms.

Crofford, Nashville: Thank you for those comments Mark, I couldn’t agree more.

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7 Ways to Relieve Work Related Pain at Home

If your job involves heavy lifting, squatting, bending, repetitive motion, or any activity that puts regular demand on your muscles and joints, you’re probably no stranger to pain. Here are a few refreshers, and perhaps brand new approaches, for you to try at home as you manage your job-related achiness, stiffness and pain.

1. When it comes to work-related pain, start with prevention.

Strains and sprains are common types of workplace injuries that can cause pain. Some of the most frequent causes of strains and sprains are:

• Excessive force
• Excessive repetition
• Poor posture and lifting techniques
• Poor health, including smoking, excessive drinking and unhealthy weight
• Not enough rest and recovery
• Poor nutrition, fitness and hydration
• Stress

Some jobs simply require exertion, force, and lots of repetition, and there will be no immediate way to change that. However, you can start to become aware of your body mechanics (ergonomics) on the job. This is about positioning yourself and your tools so that individual muscles don’t have to do too much of the work.

2. Use electrotherapy (TENS) for relief of aches and pains resulting from work.

Doctors, physical therapists and chiropractors have employed Transcutaneous Electrical Nerve Stimulation (TENS) in their offices for more than 30 years, it is available today for home use. TENS units, as they are called, use safe, mild pulses to offer temporary pain relief. This kind of electrotherapy is best for acute muscle and joint pain located in a local area that has lasted less than three months.

Tips for using a TENS unit at home:

• To get the right effect, follow the instructions on your TENS unit carefully
• Start with a 15-minute session
• Rate your pain from 1 to 10 before, during and after
• Start soon after you receive the injury or notice pain

There are different reasons TENS units are effective. Scientific theory suggests that TENS has the ability to block pain messages from reaching the brain, to encourage circulation, and to help the body produce natural endorphins. TENS is a healthy alternative to over-the- counter or prescription drugs.

For more information on TENS click here.

3. Is your pain acute or chronic? Use temperature therapy the right way based on your answer.

Heat and cold are both effective ways to treat injuries and the pain that follows from them. However, it’s important to apply the right therapy at the right time to avoid making injuries worse.

Cold for new, heat for old

A general rule of thumb is to use ice for sudden, intense pain and swelling and use heat for chronic aches and pains. (Note that your heat source should always be warm, not hot.)

By this hot and cold rule, you might apply ice to a fresh injury. Then, after the acute swelling and intense pain are relieved—which could take hours, days or weeks—switch to heat. Heat is ideal for the longer-term stiffness, soreness and achiness that follow an injury.

One general guideline is to use ice for injuries less than six weeks old and warmth for injuries more than six weeks old, and also for arthritis.

Common warm and cold therapies for job-related pain include:

• Heating pads
• Heating packs
• Hot towels
• Warm baths, whirlpools and saunas
• Warm baths with epsom salts

Cold sources:

• Ice packs
• Cold sprays and gels

4. Use pain medication safely and responsibly.

Ibuprofen, acetaminophen and aspirin are all safe forms of pain relief when used as they are intended. Even though these pain medications are available over the counter, they are still serious drugs. Abusing them in the short term or using them for a very long time can contribute to kidney disease, strokes and bleeding disorders.

The opioid epidemic

Drug overdoses are now the number one source of injury in the U.S. The opioid epidemic, as it’s being called, is partly to blame. Oxycodone, morphine and illegal drugs like heroin are all examples of opioids. Legal opioids are only effective for temporary pain relief, and should never be used without a prescription or without careful monitoring from a doctor.

5. If pain supplements are supported by evidence, try them for work-related pain.

Research shows some supplements may have a beneficial effect for managing pain on and off the job. Here are a few.

• Glucosamine for pain from osteoarthritis and knee osteoarthritis
• Turmeric for knee osteoarthritis
• Capsaicin, applied topically for joint pain

A note on the term “osteoarthritis”

Osteoarthritis is the most common chronic joint condition, and it’s characterized by achy, stiff and painful joints. Osteoarthritis results from wear and tear. Lifting, bending, straining, repetitive motions, and other work-related activities are all suspects. But you don’t have to be diagnosed with osteoarthritis to benefit from pain-management techniques.

6. Consider an anti-inflammatory diet to help manage chronic pain.

Inflammation is the body’s response to injury. The heat, redness, swelling and pain caused by inflammation can become chronic. Fish, other foods with Omega 3 fats, and antioxidant-rich foods all may play a role in reducing unnecessary inflammation. On the flipside, trans fats, refined sugars, deep-fried foods and red meat may be pro-inflammatory foods.

7. Use healthy, low-impact exercise and strength training to reduce pain and improve flexibility.

Movement

The last thing you may want to do after a day of hard labor is go to the gym. However, movement has a very beneficial effect on relieving pain. Yoga, Tai Chi, swimming and biking are just a few examples of exercises that help circulation, promote flexibility and help fluidity of joint movement.

Core strength

In addition to exercising your joints through movement, safely exercising your muscles with strength training may benefit you on the job. Healthy strength training, preferably under the coaching of a physical trainer, won’t just make it easier to lift heavy objects. It can also take the load off of isolated muscles that are working too hard.

(Yes, the old cliché of “lifting with the legs” applies. Squats are just one example of a strength-training exercise that makes it easier to lift with the legs, taking strain off of your back.)

Safely fitting exercise into an active life

Exercising in the mornings, on your days off, or in the evening after you’ve had time to rest are ways of working exercise into your active life. The importance of rest can’t be emphasized enough. Work with a physical trainer to get guidance on planning out your rest days.

Prevention techniques, especially body mechanics/ergonomics, are the best way to defeat work-related injuries and pain. For those inevitable times when physical work does lead to aches and pains, TENS units, hot and cold therapy, nutrition, supplements and safe exercise are great ways to lessen the effects of routine sprains, strains, wear and tear.

90,000 Why is pain pleasant? – BBC News Russian Service

• Zaria Gorvett
• BBC Future

October 19, 2015

Photo author, Thinkstock

Photo caption,

Exercise at the limit causes pain bordering on pleasure

Why some do people like scorching hot spices, physical activity at the limit of human capabilities or sadomasochistic sex? Correspondent

BBC Future decided to find out what pain and pleasure have in common.

His opponent was famous for his cruelty – for many, the fight with him ended in convulsions, a heart attack or even death. But entering the arena, Jason McNabb looked surprisingly calm. The whistle sounded. The battle was swift and terrible – tears immediately flowed onto the swollen lips of the daredevil soaked with sweat.

It was an unusual competition. McNabb set the world record for eating the “ghost pepper” Bhut Jolokia within two minutes. “It seems like I got a mouthful of wasps, and they all began to sting me at the same time.Hellish pain, to be honest, “- admitted the thrill-seeker.

Scoville’s hotness index on the Scoville scale exceeds a million units – in other words, it is 200-400 times hotter than jalapenos. This pepper is one of the hottest in the world and even a small piece can cause unbearable pain in a person, which begs the question: who would think to torment himself like that?

Common sense suggests that people tend to seek pleasure and avoid pain, but this is not always the case.Some people enjoy pain-inducing activities such as running, hot stone massage, tattooing, body piercing, and even BDSM (short for psychosexual practices such as bondage, discipline, dominance, submission, sadism, and masochism).

Hunting more than bondage

For McNabb, the pain inflicted by hot peppers causes a wave of pleasure, comparable to the pleasure of food, drugs or sex. According to him, “the pain subsided rather quickly, there was only pleasure from the adrenaline rush and a feeling of euphoria.”

Photo Credit, Guinness World Records

Photo Caption,

Jason McNabb, Chili Pepper Champion, calls this pain hellish

The connection between pleasure and pain is rooted in our biological device. To begin with, any pain causes the central nervous system to release endorphins, proteins that block pain and act like morphine like opioid drugs, causing a state of euphoria.

Runners are familiar with this phenomenon. Intense physical activity promotes the release of lactic acid, a breakdown product of glucose in the absence of oxygen in the body.

The acid irritates the pain receptors in the muscles, which send electrical signals through the spinal cord to the brain. At the level of the senses, these signals are perceived as a burning sensation in the legs, which usually causes the runner to slow down or stop.

But then the hippocampus, the control center of the nervous system, interferes with the process. This seahorse-shaped brain structure responds to pain signals by stimulating the body to produce its own drugs, endorphins.

Proteins bind to opioid receptors in the brain and inhibit the release of substances involved in the transmission of pain signals.

This not only blocks pain, but also stimulates the limbic system and the prefrontal cortex of the brain – the same areas that are aroused by passionate love and music – causing pleasant sensations similar to morphine or heroin.

Photo author, Thinkstock

Photo caption,

Runners experience pleasure after prolonged exercise.What happens at this time in the brain?

In addition, pain from intense physical activity stimulates the release of another pain reliever produced by the body – anandamide, also called the “bliss molecule”.

Anandamide binds to cannabinoid receptors in the brain, blocking pain signals, creating a feeling of warmth and pleasantly blurring the mind, similar to marijuana, which binds to the same receptors. Excitement is enhanced by adrenaline, which is also released in response to pain and increases the athlete’s heart rate.

It is believed that the burning sensation in the legs helps to avoid overload, while the pleasure of running, apparently, helped our ancestors to overcome fatigue during a long hunt. In general, scientists believe that the pleasant sensations that replace pain have evolved to help humans cope with the effects of trauma.

The theory of “light masochism”

But why are some types of pain pleasurable and some painful?

One explanation is based on the theory of “mild masochism”, which implies that people desire pain, provided they are constantly aware that this pain is not a signal of serious harm.Animals are incapable of this.

Photo by Thinkstock

Caption,

Hot chili peppers can feel good … ultimately

One example is chili peppers. Its active ingredient capsaicin is completely harmless. It causes pain because it binds to the TRPV1 receptor, a family of temperature-sensitive receptors on our tongue that alert the body to potentially dangerous heat or cold.When TRPV1 is activated, the same signals are sent to the brain as if the tongue were on fire.

Most young children refuse to eat chili, but after trying it several times, they learn to enjoy the hot pepper, as it ceases to be associated with real physical harm. At the same time, the tongue of a hot pepper lover is as sensitive to capsaicin as that of any other person.

Only a human can experience pleasure from pain. Attempts by scientists to instill a love of chili in rats were unsuccessful.

Animals can be trained to hurt themselves, but only through “positive reinforcement” when they associate pain with reward. “Usually, if an animal gets a negative experience, it tends to avoid it in the future,” explains Paul Rosin, a researcher at the University of Pennsylvania (USA).

Photo author, Thinkstock

Photo caption,

Professionals of the sex industry distinguish useful pain from harmful

For those who are fond of BDSM, there is nothing surprising in the concept of “light masochism”.

Ms Alexandra, a professional sadist from London, says: “We distinguish useful pain from harmful pain. Harmful pain tells us that something went wrong, and we immediately pay attention to it. But there is also useful pain that gives pleasure. For example, if during bondage begins to pull the shoulder, it can be unsafe, and we loosen the knots. ”

This theory is also believed to explain why people seek and find delight in notoriously unpleasant experiences such as chilling roller coasters and watching sad movies.”If the animal rolled on a roller coaster, it would be frightened and would never climb on them again,” says Rozin.

Secrets of Paracetomol

The relationship between sex and pain is not limited to the world of BDSM. A study was conducted in which scientists using functional magnetic resonance imaging studied the brains of women, while they brought themselves into a state of orgasm.

Photo author, Getty

Photo caption,

Common sense suggests that people tend to seek pleasure and avoid pain, but this is not so. including those that are responsible for pain.In another study, scientists found that cancer patients who had their spinal nerves removed to relieve chronic abdominal pain lost the ability to experience orgasm. At the same time, with the resumption of pain, this ability was restored.

Barry Komisaruk, at Rutgers University and author of the tomographic study of the female brain, believes there is a deep connection between the metabolic pathways of pain and orgasm. “It has also been observed that facial expressions during orgasm are often indistinguishable from grimaces of pain,” says the scientist.

Similar conclusions were made when studying the effect of paracetamol on the emotional state: it turned out that this analgesic not only relieves emotional suffering, but also dulls pleasure.

In this study, students were given paracetamol or a placebo and were asked to rate the intensity of the sensations when viewed from a series of provocative photographs.

Under the action of the drug, positive and negative emotions weakened equally, which indicates that paracetamol functions at the level of common biological channels.

We have to admit that pain and pleasure in a person are always closely intertwined.

How does pain work and why can’t it be tolerated? Interview with a specialist in the field of brain physiology Vyacheslav Dubynin

Why is pain needed? Is it true that people with red hair are most sensitive to it and how can mental pain develop into physical pain? What determines the individual level of pain threshold?

Why do people experience pain differently? Is it true that women tolerate it more easily? How does the placebo effect occur and at what stage of life does a person develop pain threshold? About this BFM.ru spoke with Doctor of Biological Sciences, Professor of the Department of Human and Animal Physiology, Faculty of Biology, Moscow State University, specialist in the field of brain physiology Vyacheslav Dubynin. Ekaterina Kukharenko and Nadezhda Donskikh talked to him.

Katya : Pain has evolved to avoid injury. Thanks to the pain, we pull our hand away from the hot stove, avoiding a serious burn. On the one hand, pain helps us live. On the other hand, it still sometimes makes life unbearable.

Vyacheslav : That’s right. Pain is an alarm system that says there is something wrong somewhere. It occurs when our cells and tissues are damaged. The damaged cells release chemicals, also called the “SOS signal”, and they form our pain sensations. But the problem is that, unlike the car alarm, we cannot just turn it off. If I don’t want to see something, I close my eyes; if I don’t want to hear something, I close my ears, but pain is more difficult.Therefore, she sometimes works too intrusively.

This is an example of the fact that evolution, when creating our organism, does not create perfection. She creates a kind of working option. Survive, multiply – forward. And perfection will be sometime in the future, maybe in a million years. Off buttons no, and therefore people sometimes have to suffer from this – I already know that my arm is broken, and it hurts and hurts. Well, that’s it – it was handed over with imperfections.

Nadia : But not feeling pain at all is also dangerous.Congenital insensitivity to pain is a rare genetic disorder. Why is it so difficult both without pain and with it?

Vyacheslav : An alarm is still needed. What you said is, of course, a rare story. But there are quite a few people who, for example, have a damaged spine. They move in wheelchairs, their legs are paralyzed, and they do not feel, say, the entire lower body, touching their legs, do not feel pain, and for them this is a daily problem.They have to look all the time to see if something has happened there, because it is very easy to get scalded or hit on something. Therefore, it is bad without alarm, when it is too sensitive – too. But without alarm, it’s worse.

Katya : Why do people feel pain differently? Does it depend on the specific organism? Kenneth Hansraj, head of the New York Center for Spinal Surgery, once said: “Someone can drill the tibia without anesthesia, but he will calmly tell you, they say, buddy, get this thing out! And the other cannot even bear the touch of a thin needle to the skin. “Why is this happening?

Vyacheslav : As for the tibia and its drilling, I think he exaggerated a little – I think there are maybe one in a million such heroes, or maybe even fewer. But about intolerance, intolerance to mild pain, this is a fairly common story. We are unique at the level of genes, at the level of the brain, because when our brains form and nerve cells make contact, a unique combination occurs, and even twins have different brains. We have a unique immune system.By the way, the perception of pain is still very strongly related to immunity, because along the course of damage, not only pain occurs, but also inflammation. And the inflammatory response tends to make the pain worse, and the pain intensifies the inflammation. Such a feedback system. Depending on all these attitudes, we react differently to pain, but, apparently, the main difference is in the head. Because each of us has rather individual pain perception thresholds, and we know the nerve centers that are responsible for this.If the activity of these centers in a person is high, it will be easier to endure pain.

Nadia : And there is also the idea that men and women endure pain in different ways, women supposedly find it easier due to biological characteristics. It is believed that a woman needs this pain threshold to make it easier to give birth.

Vyacheslav : Well, I didn’t give birth myself, I don’t know, but, of course, colleagues, acquaintances who gave birth, told me this many times, especially, of course, the first birth.And plus more fears, because those signals that are sent by the cerebral hemispheres are added to this. This is a logical explanation, we even know the zone that is responsible for this – the central gray matter of the midbrain. It triggers the release of special molecules, primarily serotonin molecules, and they partially block pain signals that go to the spinal cord. Because if we are talking about the same childbirth, well, in general, arms, legs, torso, then first the pain signal is read by the spinal cord. And it is at this level, at the level of the pain signal input to the brain, that part of the information can be blocked, the signal can be weakened.This is where this serotonin works.

Katya : At what stage of life does a person develop a pain threshold? Or is it, in principle, passed on from the parents at the genetic level?

Vyacheslav : As always in such stories, 50-60 percent are genes. You can inherit a higher or lower pain threshold from your parents, but then, if you live in a completely greenhouse environment and dust particles are blown off you, your pain threshold will remain at low values, and you will be very sensitive to pain.And if you all the time run after prey through thorny bushes, gradually your pain threshold will begin to rise. That is, the brain learns to regulate it in a rather limited size. A lot of information is provided, for example, by comparing these thresholds and, in general, the sensitivity of people of different nationalities. For example, the Far North – there are also very extreme conditions, and people whose nationality was formed there have high enough thresholds for the perception of cold and pain.

Katya : To dot the i’s once and for all: what is low and high pain threshold?

Vyacheslav : Low pain threshold means that you react even to mild pain.Imagine that there is a river and a dam. If this dam is low, then even a not very full-flowing river will overflow through it. And a high dam – here it is necessary to fill as a reservoir. Accordingly, in order to overcome a high pain threshold, a very strong flow of pain is needed.

When we study the pain threshold in experiments, for example, we test an anesthetic drug on a person, two metal rings are put on your finger, between which impulses of electric current are passed, and you have a button.The first time you press when you feel pain, and the second – when this pain is already unbearable. There are two parameters – pain threshold and tolerance threshold. These are separate indicators. The second indicator already captures the emotional perception of pain, which is also very important, because pain is a negative emotion. And these emotions are needed so that we pay attention to pain. Because pain as a signal has the first priority. If someone is chewing on your right side, you have to drop everything and sort it out. There is no time for sight, not for hearing, because we are talking about damage to the body.Pain is a signal that someone is damaging your cells and tissues.

There is also the concept of chronic pain. When in some place something hurt for a long time, for example a tooth, and then you cured it, but the pain remained. In this case, sometimes it is necessary to destroy the entry point of the pain signal into the cerebral cortex. Neurosurgeons know how to do this very subtly. At one time I even had to participate in such works.

Nadya : That is, if a toothache persists for a very long time, although the tooth has already been cured, you need to go to a neurosurgeon?

Vyacheslav : It looks like this: you have a toothache, they reached pulpitis.The doctor cured the tooth, removed the nerve, the frost was gone, and the tooth continues to hurt. Then you go to your dentist first, say: what’s the deal? And he: “Dear, due to the fact that you endured pain for too long, your brain underwent changes, and now the pain signal appears literally from scratch, it is enough sometimes to touch the place where the tooth was, but it already hurts, and now it is no longer to the dentist, but to the clinic of facial pains. ” Not immediately to a neurosurgeon, at first they will try to cope with these drugs, approximately the same ones that are used in the treatment of epilepsy.With epilepsy, when convulsions, drugs are needed to slow down the brain. And they sometimes help relieve this chronic pain. Now, if they do not help, then there is the last line of defense – this is a neurosurgeon, but this must be done absolutely. A similar story not only with a tooth can happen, but with any part of the body, especially if there was some kind of strong and long painful effect. Unfortunately, our brain is designed in such a way that it is able to remember this long pain and then generate it, even if the signal source has disappeared.Therefore, it is not recommended to endure pain at all, because every time there are risks of such damage. The next time, there is a great chance that the pain will be easier and stronger. This “I never take pills, let my head hurt, it will go away by itself” – this is a very bad idea, very much.

Nadia : Yes, many people do this because they do not want additional chemistry in their bodies and suffer such mild pain.

Vyacheslav : Well, in vain. This is the risk of increasing, increasing pain over and over again and entering some pathological situation such as chronic pain.Bad idea.

Nadia : How does the pain shock form? Military medics and journalists described cases when soldiers, after being seriously wounded, experienced almost no pain, although in fact there were quite serious injuries and the pain should have been almost unbearable. How is this possible?

Vyacheslav : This is not a painful shock, but on the contrary, analgesia. Algos is Latin for pain, and analgesia is the denial of pain, pain relief. Indeed, we have such a structure in the brain, it is called the “blue spot” and is located very deep in the brain.There, nerve cells are very powerfully activated during stress and secrete another very important molecule – norepinephrine. It can also block pain signals at the entrance to the spinal cord. Our basic pain sensitivity, that is, pain thresholds, depends on serotonin. And norepinephrine determines how stress now affects your perception of pain. And with severe stress, the pain is really very much “cut down”, and this is evolutionarily logical, because if you got involved in a fight, then the pain should not bother you, that is, a state of “fighting frenzy” sets in.This is very expensive for the body, but it allows you to remove unnecessary factors during a fight, aggression. We’re very aggressive. We have had so many of these fights in our evolution, and they still remain, so this mechanism works.

There is a reverse story, which is more often called a pain shock: when the pain is so strong that a terrible heartbeat begins, a rise in blood pressure and in general you can die.

Katya : In general, pain is a rather complicated, complex story.Can pain be divided into two main components: sensitive – understanding how much and where it hurts, and emotional – that is, the suffering caused by this pain?

Vyacheslav : That’s right. The hypothalamus, a special structure deep in our brain, does this. Yes, these are two different components – sensitive and emotional. And each one works separately. Sensitive allows our cerebral cortex to understand where it hurts, and to do something, pull out the splinter.And the emotional one allows us to learn so that next time we do not climb into the bushes with thorns. Against the background of this negative emotion, we learn to make our lives safer.

Katya : Lobotomy was used in the middle of the last century. Can we say that after the person felt pain, but emotionally he no longer suffered from it? Do pain relievers work in a similar way now?

Vyacheslav : Let’s take turns. Lobotomy is a rupture of signal transmission from the hypothalamus and similar structures to the frontal lobe.And yes, you say correctly, emotional perception disappears, and in general, with a lobotomy, all emotional perception disappears. A person loses what is called motivation. That is why lobotomy was invented to turn off severe schizophrenics or manic disorders. But this, of course, was a creepy idea, and this is a black stain on the reputation of neurosurgery. It was abandoned as soon as drugs appeared that could block the centers of emotions – antipsychotics. And as for painkillers, no, the main painkillers act in the focus of inflammation, not even in the brain, but where tissue cells are damaged.Aspirin, analgin, ibuprofen, diclofenac are molecules that do not affect the nervous system at all, but the focus of inflammation and reduce it. They are practically not addictive, addictive, and you have to try very hard to cause some harm to the body with the help of these drugs, so they are sold without a prescription. But they work for fairly mild pain. When the damage is large, drugs are needed that block the pain signal at the entrance to the spinal cord or brain. Because our spinal cord is responsible for the arms, legs, trunk, and the head is a completely separate system, it is called the “trigeminal nerve”.The logic is the same: there is control of the pain threshold at the entrance, and there are drugs that block pain at the entrance – morphine-like ones. And since morphine and its derivatives also have a narcotic effect, that is, they cause positive emotions and euphoria in a completely different area of ​​the brain, a very difficult story turns out: a group of very important drugs that allow any pain to be controlled, at the same time also a terrible drug. Therefore, this is all purely prescription and under control.

Katya : In some simple cases, the same homeopathy and placebo often help.

Vyacheslav : It seems to me that the rumors are somewhat exaggerated. This all works in a situation of relatively mild pain. And the fact is that the concept of “pain threshold” applies not only to the level of the spinal cord, but also to the level of the cerebral cortex and our subjective perception. And our brain is already able to block some of the pain signals here at the upper level. And if he has such an experience of blocking – well, for example, you take a pill of analgin – the headache has passed, your brain learns, remembers: yeah, ate this white thing – then pain relief occurs.And if you ate an empty pill for the 50th time instead of analgin, there is a chance that this placebo effect will work. It might not work. Because not all brains are like that. But suggested people react more easily to all this.

Winemakers conducted an experiment. You are given three bottles of exactly the same wine. One says “$ 10,” the other says “$ 100,” and the third reads “$ 1,000.” And, of course, everyone will say that $ 1000 wine tastes much better. This is the same placebo effect.And if you are very independent, then no placebo will take you. But if a doctor comes and says: “I have a super-tablet, bought for big money, it suits you and will solve many problems” – many believe. The personality of the doctor is very important – if he enjoys great authority, has aroused sympathy in you. And if you come with a sour face: “What are you doing me good here in this clinic?” – so you will not have a placebo effect, but the opposite effect – nocebo. This is when you are vaccinated, and you say: “Well, as I read, there are so many side effects from vaccinations, look, it is already swelling, ambulance to me, already suffocating.”We can convince ourselves not only that we have become better, but also that we have become worse. This is a serious problem.

Same problem with young children. It is difficult for you to explain to your child why he needs an injection. The child screams, he is categorically against any painful influence. You are just starting to smear the place of the future injection, and it runs away from you with a squeal. Derivative pain control is weaker in the child.

Nadia : It is believed that people under the influence of alcohol are less prone to pain.Why it happens?

Vyacheslav : This is with a rather serious alcoholic intoxication. Yes, because alcohol enhances the inhibition processes in our brain, and all signals pass worse – visual, auditory, and pain. We have such a molecule in our brain called gamma-aminobutyric acid. It is precisely this that is affected when, for example, epilepsy is treated. And it is also affected by alcohol in a rather large dose, starting from about 40 grams of alcohol equivalent, half a bottle of wine is obtained.Then pain sensitivity falls. A superdose of alcohol works as a pain reliever.

In fact, pain is such a total phenomenon that we can influence it through different mechanisms, but the least traumatic thing is to influence the inflammation focus. Therefore, all these aspirins, analgins are very common, sold without a prescription.

Katya : If I understand correctly, the brain itself still does not feel pain. Is he picking up all these pain signals that come from all over the body?

Vyacheslav : Feeling pain is generally a figure of speech.What does it mean to feel pain? There are nerve impulses that run from the damaged area to the spinal cord, from the spinal cord to the brain. Likewise, we can say that the brain sees nothing and the brain hears nothing.

Katya : But all brain surgeries are performed without anesthesia?

Vyacheslav : Well, how to understand, without anesthesia? First, there is serious local anesthesia – all these novocaines, lidocaines. Secondly, a large background is created by drugs that enhance the effect of gamma-aminobutyric acid, this is inhibition.That is, the person is almost half asleep. Yes, he can answer some questions, because sometimes during neurosurgical operations you need to ask additional questions in order to understand which area of ​​the brain we are affecting. I talked about chronic pain – that’s where you need to destroy a piece of the brain only half a millimeter in size. For example, for the last ten years, a person has had a terribly sore thumb. In the brain, you can find the channel where information is transmitted from this particular thumb.But this channel is half a millimeter in size, and next to it is information about other fingers, from the hand – that’s how exactly to get there? No tomogram will help here. What do neurosurgeons do? They enter the area where this channel is approximately located with the help of a very thin wire, an electrode, and then begin to stimulate this area. The person is asked: “What are your feelings?” And here it is important that he was under local anesthesia. He will say: “So, I got stabbed in the elbow area.” The neurosurgeon understands: “So, we are still quite far from the hand.”A little more passes: “And now?” “And now my middle finger has reacted.” “Yeah, we’re already in the palm area. Let’s move a little more. ” – “And now the index.” A little bit more. “And now I just hit my sore unfortunate finger.” “Oh,” says the surgeon, “we are destroying this place.” And that’s all, for a person who has had this pain for ten years, right on the operating table this pain cuts out. This is absolutely amazing. This is striking and shows how computer-like our brain is arranged and how important it is to know more about it.

Nadia : Some argue that mental pain can give a person almost more torment than physical pain. Here we are talking about the fact that if something hurts physically, then it can be drowned out with painkillers, and if some kind of grief happened, you will not eat the pill. Longer therapy is needed here. What can you say about this mental pain?

Vyacheslav : I think that most readers in one way or another have faced mental pain. We call it pain, because we sort of compare it with our sensory sensations, because both here and there – for example, the loss of a loved one and a burn of a hand – the same zones of the hypothalamus, our main center of negative emotions, are triggered.And it is there, in this hypothalamus, that all our negative experiences converge. Therefore, at the speech level, in all languages, the word pain is also used for mental pain. But about the pill – there are tranquilizers that enhance gamma-aminobutyric acid, there are antidepressants. But, indeed, sometimes a rather long therapy is needed. This is a completely different story related to your perception of the world, value system, and so on.

But this can also have consequences. Stress arises the same, and already from it some blood vessels inside your heart can shrink and your heart really gets sick from mental pain.Then physical pain is added to the mental pain. Is that possible.

Nadia : But there are people who like to be in pain. On the one hand, a whole industry is built on this, BDSM is reflected in popular culture, in cinema. This topic has long been considered something forbidden. Where does this desire to experience and hurt come from?

Vyacheslav : In fact, there are no special difficulties here. There is such a global principle of the brain – it is called the “dominant principle”.When the brain is carried away by some kind of activity, then everything, for example, sensory signals and in general all events begin to be considered from the point of view of this activity. This apparent dominant begins to work like a funnel, a black hole that sucks everything in. Imagine that you are terribly in love with someone. And now it already seems to you that this beloved person is next to you, you can see him in the movement of clouds in the sky, such a dominant is coming, and everything falls into this love sphere. A similar story can happen during sex.Because this is a very strong arousal, this is the work, by the way, of the anterior zones of the hypothalamus. The pain centers are located at the back of the hypothalamus. And this is in the front. And if the level of sexual arousal is high enough, then all sensing begins to go there, like into a black hole, including a little pain. These are not necessarily some sadomaso practices, this includes a very ordinary list with which you can bring joy to your partner. But the important thing here is that it is relatively mild pain.In people who are inclined to add pain to sex, this dominant works more strongly, and this funnel sucks in not only very weak pain signals, but also quite strong ones. But all the same, starting from a certain moment, instead of the sexual moment, defensive [behavior] is turned on.

By the way, this is typical not only for humans. Physical intimacy in many animals is accompanied by the infliction of physical pain on the partner. It is needed in order for ovulation to take place effectively. There are animals in which an egg cell will not form at all without pain.Therefore, all this can be viewed from the point of view of the dominant and the fact that during such a vivid physical intimacy, even weak pain signals can work for sexual behavior and for getting pleasure from contact with a partner.

Katya : So biologically it’s absolutely normal?

Vyacheslav : The point in this case is the quantity. If the level of pain is very high, then it is already somewhere in the border zone. Is it normal or not normal – doctors, psychiatrists, lawyers are already breaking spears here.Because the concept “norm is not the norm” is very vague. Sometimes the World Health Organization gathers and says: “We used to think it was a disease, but now we consider it a variant of the norm.”

Nadia : It’s just human nature to avoid pain. Here, it turns out, on the contrary, a person goes against his instincts.

Vyacheslav : A slight pain can be built into some sensations. Even if you take the gustatory system. In fact, some of the spices cause mild pain, but at the same time become a component of the overall taste sensation.Some kind of chili pepper – please, there are people who like spicy, but an ordinary person does not consume chili in such concentrations.

Katya : It’s hard enough to believe it, but in 2009 an article was published in the journal of the American Dental Association, according to which red-haired people really do not like to visit dentists, because they feel very painful. And it has been suggested that the genetic combination that produces this characteristic hair color makes people less susceptible to pain relievers, so they need a double dose.Do doctors really make some adjustments for the hair color of the patients or is it just such a theory?

Vyacheslav : This is exactly within the framework of our individual variability. Certain molecules interact with drugs in our body. And the properties of these molecules are also given genetically. And it turns out, depending on the genetic setting, even the dose of some aspirin is different for different people. Another thing is that pharmaceuticals usually do not take this into account, but when it comes to serious drugs – very even.There is, for example, a list of side effects that are more likely to occur in some people and less likely to occur in others. In general, modern medicine is increasingly driving towards a more individual approach to patients. And not only at the level “I will analyze the results of your analyzes, I will calculate and compare everything properly,” but at the genetic level. That is, looking at a person’s genetic passport, at the state of these hereditary information blocks, you can already predict the intolerance of a drug, the presence of significant side effects, or, for example, that this drug should be given in a larger dose.This is all a matter of the future.

Not all of this is very common yet, but it is gradually developing. And when 20-30 years pass, or maybe less, it will be a common story. You will be prescribed a drug based on your genetic status. The story with the redheads is just one of them. But redheads are also different. There are several genes that are responsible for the exchange of melanin, that is, the substance that colors our skin, our hair, our iris. And depending on how there are chemical transformations of melanin and similar molecules, pain sensitivity can also change.I myself know, and doctors I know say that when a bright red-haired patient comes to you, you need to be more careful, because they have a higher range of sensitivity to many drugs than the average patient. You can enter something and it will not work, but you can enter something and there will be a side effect right away. Not always, but nevertheless. It is just that with increased caution, you need to use some medications – give not the full dose, but at first only half. We are all different. This not only applies to redheads, to every person.Each person is unique and deserves a unique approach to all systems, including the pain sensitivity system.

Painful pleasure – we understand the causes of problems with an obstetrician-gynecologist

Sexual relations should give us pleasure and only pleasant sensations. In theory. Unfortunately, this is often not the case in practice. Harsh statistics tell us that about half of women have experienced painful relationships during sex at least once.And many of them experience pain on a regular basis. But at the same time, this is very delicate, and many are embarrassed to admit this, not only to their man, but also to the doctor. Meanwhile, pain during sex is not the norm, and can be a symptom of some very serious diseases! With the help of the obstetrician-gynecologist of the EuroMed Clinic Alina Vladimirovna CHAPLOUTSKAYA, let’s figure out what unpleasant sensations warn us about during sex.

How do you feel: sudden sharp pain in the lower abdomen during penetration.Also, similar sensations, but not as acute, can occur during menstruation.

Possible cause: ovarian cyst.

What to do? Consult a gynecologist and undergo an ultrasound scan. Most likely, nothing terrible happens, most cysts disappear on their own within two to three cycles. The doctor will recommend repeating the ultrasound scan after a few months to check the dynamics of the ovarian state.

How do you feel: during intercourse there is a feeling that something is interfering inside.Also, painful sensations appeared during menstruation, the urge to urinate became more frequent, and back pain tormented.

Possible cause: uterine fibroids. This is a benign tumor with different localization, it can be from a few millimeters in volume to the size of a large orange.

What to do? Consult a gynecologist. The doctor will prescribe an ultrasound scan, according to the results of which it will be possible to judge the presence of a neoplasm, its location and size.In the future, the doctor will select the treatment, it can be both conservative and surgical. The operation is the most reliable way to get rid of fibroids, and in the conditions of modern techniques, the intervention will be minimal.

How do you feel: A sharp pain radiating throughout the pelvis, sometimes in the anus, in the leg. Menstruation becomes more painful and profuse, bleeding or spotting during sex and between menstrual periods is possible.

Possible cause: endometriosis.

What to do? Without delaying, contact your gynecologist, go through the examination. Endometriosis is a common cause of infertility. Treatment of endometriosis can be conservative or surgical, this decision is made by the doctor after examination.

Online consultation with our gynecologist

How do you feel: pain accompanied by the urge to urinate. Pain when urinating is also possible.

Possible cause: infections of the urethra, bladder.

What to do? Visit a doctor, take a general urine test, according to the results of which a specialist will prescribe treatment.

How do you feel: itching in the vagina, redness. During sex, irritation increases, manifests itself in the form of pain, increased itching.

Possible cause: fungal infection, most likely a commonplace “thrush”.

What to do? Contact a gynecologist and get tested.Do not self-medicate. Buying at random in a pharmacy one of the advertised means – there is so great a chance that the process will go into a chronic stage. The doctor will prescribe the most appropriate drugs based on the test results.

How do you feel: pain during intercourse that appeared after childbirth.

Possible Cause: During labor, many women experience a ruptured perineum, or doctors perform an episiotomy (incision) to facilitate labor.At the site of ruptures or incisions, scar tissue forms, and it is this that leads to pain.

What to do? If several months have passed after giving birth, and the discomfort has not disappeared, contact your gynecologist. The doctor will prescribe an effective complex of drug therapy, taking into account the results of the examination. In addition, the doctor may recommend massage, physiotherapy, and anesthetic ointment.

How do you feel: pain when trying to penetrate, during frictions.

Possible Cause: Genital or vaginal inflammation.

What to do? Visit a gynecologist and get tested for genital infections. Your doctor will most likely prescribe treatment for both you and your partner.

How do you feel: pain during every movement of your partner, possibly spotting after sex.

Possible cause: Pelvic inflammation.

What to do? Contact a gynecologist for examination and treatment. Do not self-medicate under any circumstances! After the examination, the gynecologist will most likely prescribe anti-inflammatory treatment and prescribe complete sexual rest until recovery.

How do you feel: pain during intercourse, as well as pain during physical exertion.

Possible cause: adhesive process in the small pelvis.

What to do? When diagnosing adhesions, the doctor may prescribe resorption therapy, physiotherapy, therapeutic exercises. If conservative treatment does not help, adhesions are dissected during laparoscopic surgery.

How do you feel: Convulsive contraction of the vaginal muscles when trying to start intercourse, similar sensations often occur when examined by a gynecologist.

Possible cause: vaginismus.Usually the causes of this disease are psychological, associated with fear of sex, bad experiences in the past.

What to do? Vaginismus is treated with psychotherapy, hypnosis. Special relaxation exercises can help.

What do you feel: insufficient amount of natural lubrication, which leads to dryness in the vagina, as a result – to painful sensations upon penetration, microcracks of the mucous membrane.

Possible Cause: Either you are not aroused enough, or you basically do not have enough lubrication.

What to do? The easiest way to solve this problem is to use a lubricant that you can buy at any pharmacy or supermarket.

We have listed the most common causes of pain during intercourse. The main thing that I want to repeat once again is that you don’t have to endure pain during sex! If you feel any discomfort, see your doctor, solve the problem and enjoy life, including sexual, to the fullest!

What to do if the lower abdomen hurts? / Blog / Clinic EXPERT

What to do if the lower abdomen hurts?

Any pain in the lower abdomen is unpleasant, whether it has arisen acutely, or has been pursuing for more than one day.But is pain in the lower abdomen always caused by a disease? Of course, pain cannot be called the norm, but sometimes it is caused by rather harmless reasons. Among them, a feeling of heaviness after overeating, tension in the muscles of the lower press after hard work or sports activities, in women – premenstrual syndrome or ovulation. These pains go away on their own and do not require treatment. However, if the pain in women is intense and recurs from month to month, this is a reason to visit a gynecologist.

In most cases, pain in the lower abdomen is a symptom of the disease and indicates a malfunction of internal organs and requires a doctor’s consultation.The fact is that many vital organs are located in this area, and unpleasant sensations can speak of a variety of diseases and conditions, including those potentially life-threatening, requiring immediate hospitalization.

First, let’s define what the “lower abdomen” is. That part of the body, which is simply called the lower abdomen, includes the hypogastrium and the pelvic area. Since these two areas are anatomically poorly differentiated from each other, with the development of pathological processes, pain in any case is localized in the lower abdomen.

The only abdominal organ that can cause pain in the lower abdomen is the intestines. Pain can occur for various reasons – from banal flatulence and functional diseases – irritable bowel syndrome, to much more serious conditions and diseases such as acute appendicitis, intestinal obstruction, diverticulitis, Crohn’s disease, tumor compression.

The most common cause of pain in the lower abdomen is the pathological processes in the small pelvis, especially in young women.In most cases, the pain is due to the pathology of the genitourinary system. In women, lower abdominal pain can be associated with the following situations: menstrual irregularities, ovulation, endometriosis, ectopic pregnancy, ruptured ovarian cysts.

In men, the lower abdomen may hurt due to acute or chronic pathology of the prostate gland (prostatitis). The fact is that the prostate is permeated with a large number of nerve fibers, which makes it extremely sensitive to any external influences.

Acute urinary retention is another cause of lower abdominal pain, which also occurs predominantly in men. With this pathology, the patient cannot empty the bladder on his own and it becomes overstretched due to the accumulated urine in it.

When pain in the lower abdomen occurs, patients do not always know which doctor to consult. You should start with a therapist. He will conduct an initial examination and, if necessary, refer you to a narrow specialist.

In men, pain in the lower abdomen can be triggered by an inguinal hernia, which is dangerous by its infringement.

In some cases, pain in the lower abdomen can be caused by the pathology of the lumbosacral spine, mimicking the conditions described above.

Pain in the lower abdomen is a vague concept, it is quite difficult for a doctor to make a diagnosis based on this one complaint alone, therefore additional diagnostics is required. If necessary, laboratory tests of blood and urine, instrumental diagnostics are prescribed. Ultrasound examination is necessary to determine the size of organs, the presence of inflammatory exudate, neoplasms, in order to diagnose pregnancy.Also, for diagnostics, radiography, computed tomography, endoscopy, laparoscopy and other research methods can be used.

Treatment of lower abdominal pain can only be prescribed after an accurate diagnosis has been made. It will be aimed not only at eliminating pain symptoms, but also at eliminating the cause that caused it and, with the right approach, will give the desired result. A timely visit to a doctor plays an important role. Starting treatment at an early stage is the key to achieving the desired results.

Our clinic employs gastroenterologists, therapists, urologists and gynecologists, surgeons, neurologists, i.e. all those specialists who can clearly differentiate this, sometimes difficult, and sometimes dangerous symptom.

Pain in the region of the heart in young people

07 October

Good afternoon, my name is Lilia. I am 24 years old. Since the age of 15, I have often been bothered by pain in the heart area, they increased when I was 18, and now more and more often, the nature of the pain attacks has also changed (if earlier there was simply a rapid heartbeat that prevented breathing normally, now at one moment, at rest, the blood gives off strongly to the heart so that it seems to pop out now, then it darkens before the eyes, the blood seems to give back to the head and so on for 30-40 seconds, then, as before, shortness of breath).During attacks, I feel a rapid heartbeat, some shortness of breath, chest pain, sometimes radiating to the left side of the neck and left arm, dizziness, general weakness. Did an ECG, except for sinus tachycardia, they did not say anything, did an echo – they said that there is an additional chord, but this is a minor anomaly. She was also examined with the Holter apparatus, but on the day of the examination there was no attack and was given another similar apparatus, which recorded the attacks for 5 days, as a result, they said that the arrhythmia was, as it were, the acceleration of the heart rate from 85 to 160 at rest, of course, was not fine.But to identify the source, they also prescribed probing, which I refused at that time. We decided to postpone it when it gets worse. Could these attacks be angina attacks? Or what is it anyway ?? Is this related to the extra chord ?? Note that neuralgia and disorders of the spine have already been ruled out! Thank you in advance!

Berdnikov Sergey

Cardiologist, Ph.M.Sc.

These symptoms do not apply to angina pectoris and an accessory chord. False chords are now not considered a pathology, this is a normal and very common phenomenon. To draw any conclusions, you need ECG data, echocardiography and ECG monitoring. You can send copies of the research to our mail, but it is better to apply in person.

90,000 “Walk towards pain, don’t avoid it”: life principles of billionaire Ray Dalio

Ray Dalio grew up in an ordinary family with an average income, and now he is included in the list of the 100 most influential people on the planet (according to Time) and the 100 richest people people in the world (according to Forbes).The investment firm Bridgewater Associates, which he founded at the age of 26, became the fifth most important private company in the United States (according to Fortune) over the next 40 years. The secret of her stability and success is that Ray Dalio in his life and work strictly adheres to the universal principles, which gradually crystallized out of the patterns of victories and defeats. The power of these personal principles is such that they have changed the entire industry (CIO magazine even called Dalio “The Steve Jobs of Investing”). You will find all the rules of life and work of the American billionaire in this book.It is possible that after reading it, your life will not be the same.

Realize that you are everything and nothing at the same time, and decide who you want to be . The biggest paradox is that at the individual level, a person is simultaneously everything and nothing. From a personal point of view, a person is everything, with his death the whole world disappears. Therefore, for most people (and other species), death is the worst thing that can happen to them, and it is extremely important for them to live a better life.

At the same time, if you look at a person from the point of view of nature, his life does not matter. The objective reality is that each human is only one of the seven billion individuals of the same species that inhabit the planet today, and that as a species, human is one of 10 million other species. Earth is one of a hundred billion planets in our galaxy, which is just one of two trillion galaxies in the universe. The average duration of human life is 1/3000 of the duration of the existence of mankind, and it, in turn, is 1/20000 of the lifetime of the Earth.In other words, a person is an incomparably small grain of sand with a very short duration of existence, and no matter what he achieves, his influence will be insignificant. At the same time, a person instinctively strives to develop and wants to represent something. And he really can have some kind of influence, and each of these tiny steps is added to the others and contributes to the evolution of the universe.

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The question is what impact a person has and how he develops.Does it have an impact on other people (who, in fact, also mean nothing on the scale of the universe) or, in a broader sense, will we actually never be able to achieve this? Is it really important to influence something or someone, or are we better off forgetting about it and just enjoying life while we have the opportunity?

Who you become depends on your picture of the world. What you achieve in life depends on how you perceive reality and what you are connected with (your family, community, country, humanity, the entire ecosystem, everything in principle).You will have to decide to what extent you will prioritize the interests of others over your own and who will be in your social circle. You will constantly find yourself in situations where you have to make such a choice.

Decisions like these may seem too difficult to you, but you will make them – consciously or not – and they will turn out to be very important. Now it is incredibly interesting for me to accept reality, to look at myself from the height of the level of nature and to feel myself as an immeasurably small particle of the whole.My instinctive and rational goal is to simply evolve and evolve as much as possible by being still here and who I am. At the same time, what motivates me is what I love the most – my job and my relationship. Therefore, it seems to me that the mechanism of reality and nature is amazing and wonderful, including how I and everything else will undergo disintegration into parts and form a new whole, although it is emotionally difficult for me to accept that I will have to part with everything that is dear to me.

Learn Nature’s Lessons

Understanding the laws of nature and evolution has helped me in several ways. Most importantly, it gave me the opportunity to interact more effectively with reality and make difficult choices. I began to view reality through the prism of its mechanism, instead of arguing that everything should be different. And I realized that almost everything that at first glance seemed bad to me – for example, rainy days, weakness and even death – I perceived this way from the position of my existing expectations and what I personally wanted.Over time, I came to the conclusion that my initial reaction is due to the fact that I consider it out of context, and it is that reality optimizes everything for the whole, and not for me personally.

Strive for maximum development. Earlier, I mentioned that structures located in the neocortex are responsible for the unique abilities of logical and abstract thinking, as well as the ability to think from a higher-level position. These parts of the brain are more developed in humans than in other animals, and allow them to analyze themselves and control their development.Since a person has the ability for conscious learning based on memorization, he can develop faster and more seriously than other biological species, changing not only over generations, but also over the course of his own life. This continuous pursuit of learning and improvement leads to the fact that we are unconsciously pleased to get good results, and getting them quickly is doubly exciting. Although most people believe that they are striving for something material (toys, a big house, money, status) that will make them happy, for many it is much more and more lasting satisfaction that they realize that they have achieved success in some business.Once a person gets the thing they wanted, they rarely stay satisfied for long. Things are just bait. The desire to get something makes a person develop, and it is development, and by no means a reward as such, that is important for the person himself and those around him. This means that for most people, success is about fighting and developing as efficiently as possible, that is, quickly learning to understand yourself and the environment, and then changing in order to improve. It is quite natural that this should be so, if we take into account the law of diminishing returns *.Think about what it means to have a fortune. People who have made so much money that they do not receive (or almost do not receive) the marginal profit from this money will face negative consequences, as is the case with any other excesses, such as gluttony. Intellectually healthy people begin to strive for something else or try to discover new dimensions in familiar things – this process makes them stronger. As Freud said: “Love and work are the basis of human nature.”

Work is not always what a person earns for a living, although it seems to me that it is better when this is the case.It can be any long-term activity that requires intellectual and other efforts that contributes to personal improvement. As you may have guessed by now, I am convinced that the need to have meaningful activity is related to the inner desire of a person to improve. And relationships are natural connections with others that make us meaningful to each other and to society as a whole.

Remember: there is no result without pain. The realization that inwardly a person strives for development – and that material goods, although pleasant, will not make him happy – helped me to determine the goals of my development and its stimulation.Nobody likes to feel uncomfortable. At the same time, everything that nature does makes sense. So pain is given to a person for a purpose. For which one? It attracts attention and guides the person.

It’s a fundamental law of nature that you have to push yourself out of line to get stronger, and that can hurt. As Carl Jung said: “Man needs difficulties. They are essential for health. ” However, most people instinctively avoid pain. This is true when it comes to the body (for example, exercising for physical beauty), consciousness (for example, frustration, mental struggle, mental imbalance, shame), and especially when people are faced with the harsh reality of their own imperfection.

Pain + analysis = progress.

Avoiding pain is impossible, especially if you strive for high goals. Believe it or not, you’re in luck. If you treat the situation correctly, you will understand this, as well as the fact that it is a signal that you need to find a solution in order to move on. Getting into the habit of analyzing the causes of pain rather than avoiding it can help you develop much faster. I think when you see how much more effective it is to face the painful reality created by your problems, mistakes and weaknesses, you will no longer want to act differently.It’s all about habit.

Most people are unable to analyze in a critical situation, and when the crisis is over, they start doing other things and end up missing out on the chance to analyze what happened, which would help them learn valuable lessons. If you are capable of this at peak times (which is probably too much of a requirement), great. It is equally valuable if you are able to carry out the analysis after the fact, relying on memories. (For this purpose, I created the Pain Button application, which I will talk about in the appendix at the end of the book.)

Tests will test your strength and temper you. If you have not experienced a failure, then you have not left the comfort zone, if you have not reached the limit, then you are not trying to realize your full potential. Of course, this process, when you reach the limit, sometimes fail, and sometimes succeed and benefit from both, not everyone likes. But if you are one of those who like this, you can even “hook” on it. Life will inevitably put you in such situations, and it’s up to you whether you want to go further.

If you choose this often painful process of personal evolution, you will naturally ascend to ever higher levels. As you move up, you will begin to notice that when you are too immersed in a situation, everything seems more serious than it really is, and that most events fall into one or another category of events that repeat the past. The higher you go, the more effectively you interact with reality, achieving results to achieve your goals.What once seemed incredibly complex becomes simple.

Walk towards pain, do not avoid it. If you do not try to make your life easier, but get used to constantly acting, experiencing a certain pain, your development will go faster. Accept this.

Whenever you are faced with a painful situation, you find yourself at a potentially important crossroads in life: you have the opportunity to choose a healthy and painful truth or an unhealthy but comfortable illusion.The irony is that, if you choose the healthy path, pain will soon turn into pleasure. Pain is a signal! It’s like starting a sport – the habit of accepting pain and learning from it will help you “cross over to the other side.”

By this metaphor I mean you will develop a habit:

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• identify your weaknesses, accept them and work with them;
• prefer that others were honest with you, and not hide negative thoughts about you;
• Be yourself, not pretend to be strong if that’s your weak point.

Embrace well-meaning stiffness. I want to give people, especially those who are dear to me, the strength to cope with reality in order to get what they want. In pursuing this goal, I often deny them what they want – then they have a chance to fight for it. Emotionally, it can be very difficult, even when people understand that difficulties build character, and if I give them everything they want, it will only weaken them and in the future will make them even more dependent on someone else’s help.

Of course, most people would rather not have weaknesses. Traditional parenting and life experiences teach us to hide vulnerabilities. But people feel happiest when they can be themselves. If a person is able to accept his weaknesses, he becomes freer and more effective in dealing with them. I urge you not to dwell on your flaws — who doesn’t have them? By being open, you can change your negative old habits and gain real strength and justified optimism.

This evolutionary process of productive adaptation and recovery – the process of seeking, gaining and striving to achieve ever higher goals – concerns not only progress in the development of individuals and society as a whole. It is equally suited to dealing with failures that are unfortunately inevitable. At some point in your life, you will experience a real shock. It can be related to work, family, the loss of a loved one, an accident or illness, or the realization that the life you dreamed of is beyond your reach.It can be anything. At this moment, you may be so painful that it seems that you no longer have the strength to fight and continue to move on. Trust me, you have the strength. In the end, your success will depend on how much you understand this, even if during a crisis you don’t think so.

It is because of this that many of those who experienced a grandiose failure eventually became no less (and maybe even more) happy after successfully adapting to new circumstances.The quality of your life will depend on the choices you make during these painful moments. The faster a person adapts adequately, the better. Whatever your goals in life, your success and happiness depend on your ability to adapt and grow quickly and effectively as a person. If you succeed in this, you can change your psychological response so that what used to hurt you will now be desired.

Spinal pain

Once the ability to walk upright helped our ancestors to win the intraspecific struggle and survive in new conditions.But for this ability, humanity had to pay with problems with the spine. They are in most cases the cause of back pain.

Statistics say that almost every inhabitant of our planet during his life is faced with back pain. By the age of fifty, more than 80% of men and at least 60% of women suffer from spinal diseases. Moreover, the first complaints fall on the most active and able-bodied period of life – 25–35 years, and radiological signs of osteochondrosis can be detected already in adolescence.

Most often, pain in the spine occurs as a consequence of an improper lifestyle, and is also the result of spinal injuries, scoliosis, disc herniation, osteoporosis, spondylosis and spondyloarthrosis, inflammatory and tumor injuries of the spine. Moreover, ignoring such pains, we run the risk of missing a serious pathology of the spine and starting treatment with a delay, thereby significantly reducing its effectiveness.

Risk factors

The causes of back pain can be associated with both negative changes in the spine and the psychological state of a person.The main risk factors include being overweight, a “sedentary” lifestyle, excessive physical activity, or, on the contrary, an inactive lifestyle. Long-term regular stay in an uncomfortable position, abrupt movements, contributing to microtraumas of the spine, adversely affect the back. At risk are professional athletes, representatives of such professions as a cook, hairdresser, driver, salesman, as well as a large army of office workers. A harmful habit such as smoking also contributes to the destruction of the spine.There is evidence that the aging process of intervertebral discs in smokers occurs much faster than in non-smokers. Stress and depression, especially prolonged depression, can also provoke back pain and interfere with the patient’s recovery process.

History of recovery from pain in the spine

Treating ailments that cause back pain is not easy. As a rule, this is a whole “bunch” of diseases, therefore, the approach to them should be complex.Here it is very important for the patient to understand that the outcome of treatment will largely depend on his own efforts. Patients themselves can best tell about this.

Vladimir, 36 years old:

“For a long time, I did not pay attention to back pain, muscle cramps, headaches and dizziness. I thought it was the result of ordinary fatigue. But when my heart began to ache, I decided to see a doctor. In the clinic “Scandinavia” they explained to me that my complaints were related to the pathology of the spine and sent to the Center of Neurology and Rehabilitation on Vasilievsky Island.In addition to problems with the spine, they also revealed incipient hypertension and excess weight. Prescribed treatment: first I had to drink a course of drugs, undergo manual therapy and, finally, rehabilitation on simulators.

As a child, I went in for sports a lot, so the simulators were especially interested in me. This is the so-called David Back Concept biomechanical training complex. Before starting classes, you need to be tested. The computer program determines the initial state of the muscles and the mobility of the spine and calculates the training program taking into account individual characteristics.As they explained to me, it is very important to train the muscles in such a way that there is no “skew” and unnecessary overload of the spine. At the end of the course, testing is done again. And here it becomes clearly visible what changes have taken place.

The entire course of treatment took two months. The headaches and pains in the spine are gone, the cardiogram has improved. But I would describe the main changes in a different way – a mass of vital energy appeared, the long-forgotten ease of movement returned, which I had not experienced since my youth ”.

Competent approach to back pain

The head of the Center for Neurology and Rehabilitation of the Scandinavia Clinic answers questions. Tatyana Valerievna Beshlyaga , a neurologist of the first category .

– What should be done to prevent spinal diseases?

– Of course, physiotherapy exercises and any massage course will be useful. However, if the pain has already appeared, then all this is not a panacea.Such measures give a temporary result, since the causes that led to the pain persist. This applies to pathological or conditionally pathological changes in the spine, as well as lifestyle and nature of stress. To avoid diseases of the spine, it is necessary to strengthen the muscles of the back and constantly keep them in good shape. In general, the human body is designed to move. We must not forget about this.

– What should not be done if you have a sudden sharp pain in your spine?

– When acute pain occurs, it is always a signal that something is wrong with our body.Usually, back pain is also accompanied by muscle spasm, which limits the mobility of the affected segment of the spine, therefore, in this situation, it is categorically contraindicated to engage in violent “development” of the spine. Unfortunately, not everyone knows about this: someone begins to actively do physical exercises, independently engage in physiotherapy exercises, someone does a massage, someone takes a hot bath or goes to a sauna. All this is wrong, as it contributes to additional damage to the structures of the spine and nerve roots.And in no way contributes to the healing. Therefore, in the event of acute back pain, it is best to take an anesthetic medication and consult a doctor immediately.

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