Detailed guides to painful problems, treatments & more

Mind Over Pain

Pain can be profoundly warped by the brain, but does that mean we can think the pain away?

Paul Ingraham • 55m read

Our brains can make pain out of seemingly nothing, or ignore trauma that should be extremely painful. They don't always do that, but they can, and they do. Pain is not a reflex, not an inevitable result of tissue insult. It is a complex experience that is not just thoroughouly tuned by your brain but completely generated by it. The results are often strange and counter-intuitive, like quantum physics, but the science is clear: every painful sensation is 100% Brain Made®.1

So… does that mean can we think pain away? Just how much power does the mind have over pain? Can confidence and education cure? Can an attitude adjustment, or exorcising our personal demons, treat chronic pain? Not by force of will or a with an attitude adjustment. But there may be indirect methods. The challenge is to convince our brains that there’s no need for an alarm, and there are many ways we might be able to do that.

This overlaps with mind-body and lifestyle medicine, which mostly focus on trying to treat the root causes of pain in our lives and minds: thing like the impact of severe stress, sleep-deprivation, and poor nutrition, which can drive painful pathologies. That’s important, and this is related, but distinct: this article is about tinkering with pain perception itself.

Making pain neuroscience useful

Mind-over-pain and “mind-body” cures have always been big. In more recent history, strong evidence of the brain’s near infinite power to modulate pain has given new life to many old ideas about the psychology of pain, and spawned a new wave of optimism… and maybe false hope. The neuroscience is often used to tease patients with hopeful implications, but pragmatic advice based on it is scarce. Patients are left with the impression that pain can be muted by the mind, but are often given no real direction on how.

Just explaining pain itself can profoundly increase people’s confidence, reassuring them that the danger implied by pain — especially chronic pain — is often greatly exaggerated. But explaining pain is hard, and doing it carelessly can all-to-easily sound like hectoring patients to have a better “attitude” about their pain. We have to do better than that!

In this article, I get specific and detailed about what’s actually realistic about the “mind over pain” hope. There’s both good and bad news. Spoiler alert: your mind is not the boss of your brain, and we cannot directly order it to stand down. On the other hand, fortunately there are things that can be done to influence the brain’s pain hijinks, some Jedi pain tricks.

But you cannot hack a system you don’t understand. It’s critical to have a good sense of just how weird pain science can get. I will explain the basics here, but there’s another article dedicated to explaining the neuroscience as painlessly as possible. If you’re really determined to wrap your head around this topic, please start there:

Pain is Weird: Pain science reveals a volatile, misleading sensation that comes entirely from an overprotective brain, not our tissues

Other approaches to mind-over-pain

I’d like to put this in context a bit. There are many possible meanings of “mind over pain,” which we can split into three main categories:

  1. Psychotherapy to help patients cope with pain — which, the hope is, might also blunt pain itself via other mind-over-pain mechanisms.2 See Cognitive Behavioural Therapy for Chronic Pain, which is mostly about cognitive behavioural therapy.

  2. The role of the mind in physiology and pathology — originating mainly with the science of stress physiology, and evolving into a full-blown industry of mind-body cures for everything (not just pain). This is about the effect of the mind on the things that give rise to painful pathologies in the first place. See my articles on anxiety, sensitization, non-specific vulnerability, and mind-body connections (but this theme is woven throughout the whole website).
  3. The role of the mind in sensation and perception, which is the more neurological focus of this article. If all pain is an output of the brain — and it really is — then perhaps the brain can be convinced to knock it off. This page is all about pulling on that thread in as pragmatic a way as possible.

Obviously there’s a lot of overlap, and the other categories are also large and important. They contain entire therapeutic empires, like all of cognitive behavioural therapy, or the entire world of the physiology of stress, or a huge body of literature about “lifestyle medicine.”

And of course mind-body medicine has been rich soil for gurus and quacks.

Sarno’s legacy

Of all the prominent figures in 20th Century mind-body medicine, only Dr. John Sarno was specifically focused on pain, and more in his early years. He started out with the pet theory that unexplained back pain was caused by “tension myositis syndrome,” a painful restriction of blood flow to muscles. And what was the cause of this restricted blood flow? The mind, of course. Stress and anxiety leading to painful clenching, basically.

Sarno’s big idea had both seeds of truth and a lot of problems from the start… and then he got a bit carried away, drank deeply of his own Kool-Aid, and started claiming that essentially all health problems can all be chalked up to our emotions and attitudes. With that hyperbole, he became one of the major mind-body quacks, reaching way beyond the evidence and selling false hope to millions.

But even his original idea was about a direct effect of the mind on physiology, causing clamping down on circulation. He was hypothesizing a specific biological mechanism for pain which was affected by the mind, but not the effect of the mind on pain itself.

Leveraging the neuroscience of pain to try to treat pain is quite different. It’s agnostic about what’s going on in the tissues — what we care about here is what the brain does with those signals.


“Pain is an opinion”: Ramachandran’s excellent phrase

Ramachandran said that “pain is an opinion” — which sounds like a flaky New Age mind-over-matter theory. But Ramachandran is no mystic or guru: he is a neurologist and scientist. This passage is mainly known for the first few words, a pithy statement of the modern understanding of how pain works:

Pain is an opinion on the organism’s state of health rather than a mere reflexive response to an injury. There is no direct hotline from pain receptors to ‘pain centers’ in the brain. There is so much interaction between different brain centers, like those concerned with vision and touch, that even the mere visual appearance of an opening fist can actually feed all the way back into the patient’s motor and touch pathways, allowing him to feel the fist opening, thereby killing an illusory pain in a nonexistent hand.

Phantoms in the brain, by VS Ramachandran and Sandra Blakeslee

He then tells the story of an extraordinary cure of a man with phantom limb pain, tortured by agony in a clenched fist that was not there. With a clever arrangement of mirrors, Ramachandran created the illusion that the man’s amputated arm was restored — a sort of “virtual” limb. The mere appearance of his phantom hand opening and closing normally cured his agonizing “spasms.” He felt better because of the illusion that he was better — because he thought he was better. The mirror-cure of phantom limb pain is one of the most curious anecdotes in all of pain science. In all of medicine, in fact.

Since then, “mirror therapy” has been studied and applied in many ways. A good quality 2007 study showed that mirrors aren’t actually necessary to achieve this effect.3 Mirror therapy is probably just a “fun” way to visualize healthy movement — which also works quite well without a mirror!4

Stranger still are tales of severe pain without injury, illustrating that pain can be entirely in the mind. (Technically, it always is.) One of the strangest of these was reported in the British Medical Journal in 1995:

A builder aged 29 came to the accident and emergency department having jumped down on to a 15 cm nail. As the smallest movement of the nail was painful he was sedated with fentanyl and midazolam. The nail was then pulled out from below. When his boot was removed a miraculous cure appeared to have taken place. Despite entering proximal to the steel toecap the nail had penetrated between the toes: the foot was entirely uninjured.

JP Fisher, senior house officer, DT Hassan, senior registrar, N O’Connor, registrar, accident and emergency department, Leicester Royal Infirmary5

His pain was a “nocebo” — the opposite of a placebo.6 Extreme examples like this are rare, but probably not as exotic as you might think. More to the point, even if they are rare, for every case like this there must be hundreds more where the injury is real but the patient is convinced that the damage is much worse than it really is — with proportionately exaggerated pain. And indeed there is evidence of this: in a 2012 experiment, for instance, fear of pain made people more sore for longer after a workout.7

Happily, it also works the other way: people may feel much less pain than they “should” when they are confident for any reason, such as not realizing how bad the damage is.

Injury and pain are not in lock step with each other. And yet that is exactly what nearly everyone assumed for a long, long time. And many professionals, even though they may “know” better, often seem to forget how powerfully pain is influenced by perception, context, and meaning.

What is surprising is how malleable pain signals are—how readily the intensity of a pain signal is changed by the sensations, feelings, and thoughts that coincide with the pain. … The brain is not a mindless pain-ometer, simply measuring units of ouchness.

Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 187, 193


Part 2

Can We Think the Pain Away?

I have good news and bad news…

100% of the time, pain is a construct of the brain.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

If that is true — and it really is technically true8 — does that mean can we think brain-built pain away? Can our minds un-build pain? Yes and no, because, as Dr. Moseley explains, “Pain really is in the mind, but not in the way you think.”9 This is a good news, bad news kind of thing. I will get to the good news, but let’s get the bad news out of the way first:

It’s not really possible to think pain away in general. Many wise, calm, confident optimists still have chronic pain.

Pain is a motivator. It exists to get us to act. We hurt when our brains reckon we should do something differently, for safety … but safety is not always possible. The nature of the danger isn’t always clear, or avoidable.

And the brain worries too much: from hangnails to fibromyalgia, it overstates the danger (for rock solid evolutionary reasons), and it can’t be overruled by wishing, force of will, or a carefully cultivated good attitude. The brain powerfully but imperfectly controls how we experience potentially threatening stimuli, but I’m sorry to report that you do not control your brain.

Mind versus brain

Consciousness and “mind” are by-products of brain function and physiological state. It’s not your opinion of sensory data that counts, it’s what your brain makes of them — which happens independently of consciousness and self-awareness. The independence of brains is obvious with something like blushing:

Blushing occurs when the blood vessels of the head and neck dilate and become infused with blood. It is an instantaneous physical change seen on the surface but reflecting a feeling of embarrassment or happiness that is held inside. When it happens I can’t control it. That point is important. My blushes betray a feeling and, even when they increase my embarrassment, I cannot stop them.

It's All in Your Head, by Suzanne O’Sullivan, 3

But it is also true of pain. As Todd Hargrove put it, “Pain is sometimes immune to logic,” because pain is handled by a part of the brain that is not easily over-ruled by other brain “modules” — like an optical illusion that you can’t “un-see” even when you understand it.10 As he put it elsewhere:

Humans don’t get to decide what they find threatening, stressful or painful any more than a cat does. That decision is left to ancient unconscious systems that can’t really be reasoned with.

Todd Hargrove, Treat Your Client Like a Wild Animal

And that is why many wise, calm, confident optimists still have chronic pain. Your brain modulates pain based on factors that are completely out of your control. Or rather difficult to control, or even just impractical to control.

But it’s not hopeless. We have some leverage, albeit usually indirect. This is the first sparkle of good news in this story.


Three cool 😎 examples of the power of brain over pain (but not necessarily “mind”)

Here are some examples of ways that the mind definitely has power over pain, but without much practical value, at least so far: being in love, looking through filters, and not looking at all! These are mostly examples of our lack of mental control over pain, but they also point to some potential opportunities to workaround that limitation.

Romance as a pain-killer

Thanks to a quirky 2014 study, science has confirmed that being in love relieves pain — a wonderful example of the potential power of the mind over pain.11 Falling head-over-heels is not exactly a convenient solution. As researcher Dr. Sean Mackey put it, “We can’t give you a prescription for love” — not one that’s easy to fill, anyway. But we can work to give love more of a chance to grow and thrive. You can’t benefit from the pain-killing effect of love if you aren’t in love.

Closely related: pain is also muted when romantic partners hold hands. Aw.12

Weird illusions! Shrinking pain with de-magnification

If you view a painful hand through a magnifying glass, it will actually get more swollen and inflamed — that is, if you make it look bigger, it will feel like a bigger problem.13 And the reverse is true too! Use optics to make it look smaller, and swelling will go down. Incredible, right?

But … do you have a de-magnifying glass handy? Where do you buy even one of those, let alone a big one? (They really are hard to find. How about looking backwards through binoculars? Not a great solution.14) And what happens if the pain isn’t in a place that’s so easy to de-magnify, like your low back?

The de-magnification trick is dang interesting, but it’s obviously not a practical approach to most pain. The effect is real under the right circumstances, but trying to use it as a treatment is like trying to take a magician’s trick home with you.

Maybe someday virtual reality tech will make “visuotactile illusions” like this a lot more accessible and convenient. A nifty proof-of-concept study demonstrated that a couple of other illusions can reduce osteoarthritis pain by up to 40%, at least temporarily.15 So what visual sorcery can kill more pain than any other known treatment for that condition? Two similar illusions, using virtual reality goggles to make it look like the knee was either shrinking or stretching. 😜 Whoaa, duuuuude …

Not looking! What you can’t see can’t hurt you (as much)

Getting an injection actually hurts less when you don’t watch.16 Out of sight, out of mind: if the brain can’t see the threat, it is less sensitive to it. That’s interesting, and like the magnification/stretching/shrinking experiments, it clearly demonstrates that the brain modulates pain and, in that circumstance, we can modulate it. It’s easy to look away from a needle, but with most chronic pain, what is there to avoid looking at? We usually can’t see the threat.

Although it is technically the brain’s prerogative to ignore painful signals from your tissues, that doesn’t mean that there’s any way we can convince it to do so — if there is a destructive disease process going on, for instance, the brain will usually not ignore those signals! The pain system evolved to report problems, and you can count on it to do so most of the time.


How pain education can go awry

There’s an important idea that the first line of defense against pain is to understand it: pain education. The hope is that just knowing that pain is often an exaggeration of the reality in your tissues is actually a pain-killer. Whether or not that actually works when done right is something I’ll get into below.

Unfortunately, I think it’s routinely getting oversimplified to the point of rendering it useless. Too many patients are getting only a basic explanation, without any substantive discussion of the practical implications. It’s not really surprising to see this coming from individual clinicians, but I also see it coming from much more carefully prepared educational resources.

For instance, there’s a very nice Australian video about pain — it does a great job of explaining the neurology of pain. Its main messages are mission critical stuff, and I give an A-grade to their explanation of the nature of pain. But I have some nitpicking to do…

Their advice to pain patients? The application of the information? Not so good! Much too trite and impractical. The video comes dangerously close to just advising patients to “don’t worry, be happy” and it flirts with the dreaded “all in your head” implication — and that’s really not what we want here.

Yes, pain is indeed a brain thing, but this must not be dumbed down to the point that people have no idea what to do with it or, much worse, feel blamed for it. People with chronic pain feel bad enough already!17

The video portrays pain as a problem with a dysfunctional brain that can be “trained” back to good behaviour, like a terrier with behavioural issues. That is way too optimistic. Brains are not terriers. Although it makes sense to try, there is no good evidence that this actually works, and clearly it’s just impossible in some circumstances. There are many possible reasons why.

For instance, mood disorders (depression, anxiety) and stressors can be virtually invincible. Most people with chronic pain aren’t just a little stressed, they are a lot stressed, and often by major life challenges and social injustices that they absolutely cannot solve.18 Even when those problems are theoretically more manageable, most people find it extremely difficult to troubleshoot their own mental health. So while it’s technically correct to tell patients to “learn to reduce stress” and “consider how your thoughts and emotions are affecting your nervous system,” that advice is shallow to the point of being useless. The video sinks all the way down to advising us to “recognize deeper emotions.” 🙄 I think most patients will dismiss that as insultingly flaky. Don’t underestimate how hard that kind of talk can rub people the wrong way. Consider this comment I got by email:

Your ‘nitpicking’ of the cute cartoon video — which had already infuriated me before I found your analysis — was just spot on. You so eloquently expressed my feelings that I almost wept. And I’m English! We don’t do that!

I applaud the emphasis on psychological and social factors, but it’s also really important to keep it real and make it practical.


The science of confidence: does it reduce pain?

How do we convince people in pain that we understand that they are in pain but it’s not just about the tissues of their body? A key conceptual shift that we think is really important is that you can understand that pain is the end result, pain is an output of the brain, designed to protect you … it’s not something that comes from your tissues.

Lorimer Moseley, from his surprisingly funny TED talk, Why Things Hurt 14:33

Confidence can probably reduce pain, directly and/or indirectly. It’s time to start focusing on the positive implications of the brain’s role in pain, and the power of confidence is a good place to start.

One of the top five questions I am asked, about any condition, is simply Is there hope? The answer is nearly always the same: yes, there’s hope. There’s never a guarantee, but there’s always hope, and recovery from most kinds of severe chronic pain is not only possible but fairly common. Unless you have a known serious aggravating factor — a major trauma, for instance — there is almost never any reason to fear that recovery from any chronic pain problem is impossible. For the same reason that pain can be absurdly persistent and out of proportion to any clear cause — because it is so brain-tuned — it also never rarely loses the potential to finally shift and evaporate.

For instance, just a change in confidence can make a big difference.

There’s been a lot of indirect evidence about this for a long time, but one of the first really good, direct scientific tests was finally published in 2013 by Vibe-Fersum et al.19

Classification-based cognitive functional therapy (CB-CFT, or just CFT) for low back pain is a “body/mind approach to understanding and managing this complex problem” that “targets the beliefs, fears and associated behaviours” of patients (what I have called the “confidence cure” for many years). The big idea of CFT is that the cycle of pain and disability can be broken by easing patient fears and anxieties, specifically “reframing the persons’ understanding of their back pain in a person-centred manner, with an emphasis on changing maladaptive movement, cognitive and lifestyle behaviours contributing to their vicious cycle of pain.”

Translation: pretty much any strategy that restores confidence.

In that 2013 trial, CFT was tested on 62 patients with moderate back pain, and compared to 59 who were treated with manual therapy and exercise. Three months and a year later, the CFT group was much better off.20 CFT was “more effective at reducing pain, disability, fear beliefs, mood and sick leave at long-term follow-up than manual therapy and exercise.” As the authors put it for, “Disabling back pain can change for the better with a different narrative and coping strategies.”

There were some blemishes on the study methods, but nothing dire; the results can be safely regarded as actually promising21 while we wait for replication from larger studies.

So: just learning about this could be therapeutic, but how else can you apply the good news? How else can you CFT yourself, or otherwise get your brain to downgrade your pain?

Whilst the problem is superficially a physical one, the real challenges faced by someone with chronic pain are mental. Mental state is the biggest modulator of physical pain. Things hurt more when you’re stressed or sad, and the increased pain makes you both stressed and sad. The way out of this vicious circle is a wholesale change to how you perceive fear, suffering and setbacks.

How chronic pain has made me happier, by Rob Heaton


Part 3

Jedi Pain Tricks!

What are the practical applications of knowing that pain can be brain-tuned?

Chronic pain is not all about the body, and it’s not all about the brain — it’s everything. Target everything. Take back your life.

Dr. Sean Mackey, Pain & the Brain lecture

Pain is “another *%[email protected]!! growth opportunity” — an intense provocation to mature as a person. For many people with severe and chronic pain, learning coping skills is a necessity. But personal growth is a much greater opportunity than merely coping with pain. We may not control our brains, but we do have considerable indirect leverage. We can’t micromanage every sensation, but we can tinker on a large scale. We change the context and direct our experience of life on a large scale. For instance…

Animated GIF of a realistic looking brain wobbling.

Mind ≠ brain. But mind can, maybe, exert some influence on the brain, which is quite “plastic.”

Huff, puff, and blow your pain down: changing state with vigorous breathing

We can alter our physiology with deep, vigorous breathing, instantly creating new feelings — and your brain will go along for that ride, and perhaps re-interpret your experience of pain. For more about this odd idea, see The Art of Bioenergetic Breathing.

There are many similar ideas, and what they all share is changing your state in some way. I chose vigorous breathing as the primary representative because I think it’s one of the most practical and direct.

The other particular popular one — vigorous exercise — is a bit too familiar and problematic for many pain patients. Lots of pain patients can’t go for a run, or don’t want to, or can’t do it three times a day — but almost anyone can do a couple minutes of huffing and puffing five times a day.

And it’s strange and novel, and that’s a feature: when you’re trying to affect your brain, “change is as good as a holiday.”


Create new social contexts

There are many ways you can create new social situations for yourself, but playing a team sport is a really powerful one. This one is definitely not for everyone, but it is for some of us — I love playing ultimate for exactly this reason — and it illustrates an important principle.

In team sports, because other people are counting on you, the painful consequences of intense exercise are usually re-contexualized as tolerable, even desirable, and you can put up with quite a lot more. You can’t think your way to that kind of pain tolerance — but you can place yourself in a situation where it is a likely outcome.

This is why Haven — a counselling school, which many people go to just to learn more about themselves — uses “experiential” workshops, putting people through a bunch of interesting and intense experiences together. They tinker with your social context, because humans beings are so interested in each other that our social experiences utterly dominate our consciousness. Change your social experience, change your brain!


Reduce fear and anxiety, increase confidence, especially with education

And what does modern pain education look like? “It is not reciting pages from a textbook or giving a patient ‘the pain talk’.” Dr. Lorimer Moseley explains that “education is universally recommended as first-line treatment for acute and persistent back pain.”22

Fear and anxiety probably have more power to aggravate pain than any other emotional state, and acquiring knowledge and perspective are superb medicine for fear and anxiety. A confident and happy brain amplifies danger signals less than an anxious, miserable brain. This explains some interesting results in pain research (not to mention clinical observations), such as:

So seek out as much information as you can find, because nothing causes more anxiety than uncertainty, and education is a proven cure for uncertainty. One of the most important reasons to be educated is so that you have the power to be skeptical about diagnosis…


Doubt all diagnosis! Beware nocebo!

Be extremely skeptical of diagnosis — both your own ideas, and the theories of healthcare professionals. Most ideas about what causes persistent pain are bogus or exaggerated, and mostly serve to convince us that we are more broken or fragile than we actually are — causing anxiety that has real power to make pain worse. There are many classic examples, like the infamous predeliction for diagnosing back pain as a “slipped disc,” a scary-sounding, specific diagnosis that is much less common and serious than most people believe, a major reason why so many experts think of MRI as a false alarm machine.26

Meanwhile, alternative medicine churns out diagnostic speculation that is overconfident and simplistic at best. All freelance healthcare professionals, even relatively mainstream physical therapists,27 have a nasty habit of diagnosing problems that they can sell their solutions to, profitably pathologizing people, a road to hell paved with the best of intentions.28

Everyone is guilty of perpetuating this pattern — even patients themselves, who encourage it with their routine refusal to take “I don’t know” for an answer and willingness to pay for anything that gives them hope. It is vitally important to be extremely slow to believe any specific idea about what is causing your pain.


Early intervention is vital

“As early as possible” is the best time to prevent acute pain from transmogrifying chronic pain.29 It is clear that chronic pain can cause significant neurological changes, both in nerves themselves and in how their activity is interpreted by the brain, a state broadly known as sensitization — in which we feel more pain with less provocation. Pain chronification probably has many mechanisms, like becoming “pathologically emotional,”30 or even classical conditioning — a “reflex.” Remember, the theme of this article is “pain is weird”!

Regardless, however it happens, it really happens — and once those changes occur, recovery is much harder, at great cost in suffering and medical expenses. Persistent pain should not be ignored. Deal with it sooner, not later, as best you can. Don’t wait around just hoping things will get better. Obviously this is the mother of all “easier said than done” challenges, but here’s a potent practical example: a strategic temporary prescription of tranquilizers. This needs some serious elaboration…

The transition from acute to chronic pain if often a time of howling anxiety, both because of the pain and often other stresses. Treating anxiety during that transition is difficult but potentially high value and urgent, time-sensitive — this is exactly when “freaking out” may actually drive chronification! But how do you treat anxiety “urgently”? Easy: cautious use of Benzodiazepines (Valium, Ativan, etc), a modest dose for a couple weeks at most. More is flirting with disaster.31 But for that two weeks? Nearly magical anxiety relief — seriously, that stuff really works — right when you most need it (and probably better sleep too, another high-value benefit).

Naturally, you should also use that opportunity to do everything possible to start taming anxiety in other, safer, more sustainable ways: see Anxiety & Chronic Pain. Many of the other ideas here harmonize with that goal.

The brain cells that produce pain get better and better at producing pain. They become more and more sensitive …

Lorimer Moseley, pain researcher, Why Things Hurt 14:33


Reject the self-hating idea that your pain is “just” psychological or merely psychosomatic

Paradoxically, even though pain is strongly modulated by your central nervous system, it is rarely “all” in your head. Although pure psychosomatic pain probably does exist, it is disproportioantely and disrespectfully suspected and diagnosed. Using that brush to paint every other chronic pain patient is scientifically obsolete and can be thrown out with yesterday’s trash. Any health professional talking like that should just be ignored. We know better these days: pain does not have to be driven by easily diagnosed tissue damage to be “real” and serious, and it can have major psychological dimensions without being just psychological.

Patients often find themselves trapped in a zone between the worlds of medicine and psychiatry, with neither community taking full responsibility.

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

If you are going to confidently defend yourself from the corrosive idea/diagnosis of psychosomatic pain, you’re going to need a very clear understanding…

So what’s the difference between “pain is an opinion” and “it’s all in your head”?

Unfortunately, it’s tricky to tell patients “sometimes pain correlates poorly with tissue damage” without them hearing “it’s all in your head.” It’s a hazard baked right into modern pain science, and I think it’s a serious problem. I have experienced it myself as a patient, and seen lots of other evidence of it.

For example, here’s the beginning of an amazing, uplifting back pain story, told by Dr. Jerome Groopman in his book, The Anatomy of Hope, about his own experience with super severe chronic low back pain:

Dr. Rainville planted the MRI scan of my spine on a lighted box on the wall and systematically inspected the film, vertebra by vertebra. Seemingly satisfied that he had reviewed all the relevant data, he turned and stood before me.

“You are worshiping the volcano god of pain,” he declared. “The volcano god of pain is your master.”

I had been warned that Rainville was a brash, in-your-face clinician who held contrary views. But what on earth was he talking about?

The “volcano god worship” lecture Groopman gets from Rainville is really great: an intense, dramatic version of the central idea of this article, that pain can get disconnected from reality. Despite the artfulness of the explanation, Groopman struggles with the implications like any patient:

And what was he really saying, in cold biological terms, not flamboyant metaphors of volcano gods? That changing my beliefs could dampen flaming circuits of pain? Was I some mystic or yogi who could walk barefoot over hot coals or lie down on a bed of nails?

Rainville was saying that the pain was not “all in your head” but his brain’s “opinion” of the situation. Hypchondria versus sensory dysfunction. Here is that difference “in cold biological terms.”

Awkwardly, there is overlap. These two concepts are on a spectrum, and some people are undoubtedly living in the confusing grey zone in the middle. Everyone wants to believe that the weirdness of their pain is the seed-of-truth variety, a distorted and exaggerated but legitimate signal. It cannot always be that way, but it routinely is.

“All in your head” isn’t in my vocabulary

Especially the all part.

Of course I acknowledge the power of the mind to warp and magnify pain and illness — that’s well-established, in many ways. But I reject the idea that honest people ever “fake” or “perform” their suffering, consciously or unconsciously.

Objection! Aren’t there “drama queens” who seem to pour emotional gasoline on their chronic pain and illness fires?

Sure. I have met them. And there are probably some extreme cases out there.

But drama that’s actually the main driver of serious disability? The cause? I think that’s rare to the point of barely existing — especially in the absence of other conspicuous signs of mental illness.


Be kind to your nervous system

Create pleasant, safe sensory experiences — positive inputs. Seek comfort. Be a hedonist. If your brain thinks you’re safe, pain goes down — and pleasure almost always feels safe. Achieving pleasure is a good way to be sure that you feel particularly safe, at least temporary.

So be “nice” to your CNS in every way that you can think of. Make your life — or just a joint — feel safer, gentler, more pleasant. Do it in general ways (soak the whole system in a hot tub), but also more specifically: pleasantly stroke a sore knee, give a screaming shoulder the “comfort” of a sling for a while, or cautiously but thoroughly move a troubled joint to demonstrate to your brain that it’s okay. See, brain? We can do this! No big deal! Here’s that Moseley guy yet again

To reduce pain, we need to reduce credible evidence of danger & increase credible evidence of safety.

Lorimer Moseley. Explainer: what is pain and what is happening when we feel it?

Autonomous sensory meridian response as a clear, specific, sensory experience that represents safety

A strong indicator that your brain is convinced that it’s comfortable and safe is the weird sensory thrill of autonomous sensory meridian response (ASMR), a wave of euphoria with a shower of tingles over the head and upper torso.

“[The ‘ASMR effect’ is] clearly strongly related to the perception of non-threat and altruistic attention [and has a] strong similarity to physical grooming in primates [who] derive enormous pleasure (bordering on euphoria) when being groomed by a grooming partner…not to get clean, but rather to bond with each other.”32

“Bordering”? I’m going to go ahead and say that primates definitely do euphoria during grooming.

Not everyone knows the ASMR effect, alas, and it’s not necessarily easy to bring it on either (a microcosm of the whole mind-versus-brain thing). But it’s not exotic either. It is known. Its triggers are ordinary, and it often crops when while receiving quiet, focused attention from a healthcare professional, and I strongly suspect it correlates strongly with good bedside manner (not that anyone has studied that). It’s probably more prevalent in certain kinds of healthcare, like massage therapy. But ASMR has a variety of other oddly specific triggers, and the internet is full of videos intended to cause ASMR — which means that it’s something you can seek it out, like a form of meditation, but perhaps more interesting and more fun. At the least, it’s the apotheosis of pleasant, luxurious sensation, a clear indication that you are in a great “mode,” doing something to your nervous system that’s helpful for pain, substantively helping your nervous system to feel safer and less vulnerable to false alarm.

At best, ASMR might be more directly analgesic, a particularly good example of a mind-over-pain hack — you just have to get your brain into that state. Your mind must make “arrangements” that increase the odds of your brain doing that thing. You have to cultivate ASMR, which is not necessarily easy, but it is a clear and specific goal, and definitely more possible for more people than the rarefied goal of a meditative trance.

Personally, I far prefer the idea of chasing ASMR than meditation and mindfulness — even though there might be a lot of overlap.


Analgesic catharsis or “emotional release”

Does swearing reduce pain? @^#@%, yeah! And so does saying “ow!” according to a 2009 study of swearing as a response to pain:33

In our study, saying “ow” increased pain tolerance by about 20%. One may speculate that benefits in real life may, perhaps, even be larger. There, vocalisations are typically less measured. That is, people are likely to say “ow” and other things more forcefully and can do so continuously without the somewhat unnatural breaks that were introduced for standardisation in our study.

Less measured and more forceful indeed.

From cursing to catharsis: a huge but reasonable leap of logic

The analgesia of cursing isn’t at all surprising, given what we know about pain. It may not have much direct relevance to chronic pain. But it’s interesting, and fun, and it hints at a more complex possibility that has not been studied (and probably never will be): catharsis may be pain-killing.

Catharsis is renewal and restoration from through profound and extreme emotional experiences and expression. See also the obscure psychological concept of “sublimation”: the transformation of socially unacceptable behaviour into more.

In plain English? Venting. Just expressing “negative” emotions, finding “healthy” outlets for frustration, aggression, and anxiety. “Emotional release.” Some clichéd examples:

Art, history, and philosophy-based medicine

Other than a small study of the analgesic effect of swearing on pain, do we have any good reason to think that expressing emotion is useful? LOL, no. There’s not even much in the psychology literature about this as a path to improved mental health, let alone as a treatment for chronic pain.

On the other hand, catharsis is something people deeply crave. And it’s got a couple thousand years of complex roots in art and philosophy.

And it’s at least consistent with pain as a threat-sensitive system. It’s highly plausible that bottled up anger, frustration, anxiety, sadness can all ramp up the brain’s conviction that we’re in trouble. The profound relief that we can feel when we “let go” of those emotions, even temporarily, definitely might make a difference.


Change something — almost anything! — about how a painful area feels

Make a chronically painful area, and adjacent regions, feel as different as you can (and as cheaply as you can). Sensation is one of the major factors the brain considers when setting pain levels. If you can make a body part feel significantly different in any way, it may help — but probably especially if you can make it feel safe, protected, stabilized. In fact, this probably explains why many treatments for pain problems are popular and seem to help sometimes, despite being unreliable and generally minor.

Often we see inexplicable and “weird” changes in painful conditions, good and bad, and often in response to an attempt at treatment — and yet at the same time it’s incredibly rare to find good evidence that any particular treatment works better than placebo.

Classic examples include: taping, bracing, strapping, splinting, salving, vibrating, heating, icing. Regardless of how they supposedly work — there are many overly complex explanations — most of these methods probably mostly just change how a body part feels


The science of novel sensory input

Why would changing feelings result in any analgesia at all? Broadly speaking, because input changes output. Nearly anything that happens to the body has the potential to affect how the body feels and works. Pain is an “output,” and so is a lot of wet, messy biology. Tissue state is just chemistry, and the chemistry of everything is constantly micromanaged and hyper-regulated. Dysregulation and uncomfortable trade-offs and compromises in these processes are routine, but it’s still full speed ahead, all the time, damn the torpedoes, a chemical balancing act that doesn’t quit until we die. Any input may “change the equation” — the problem is that it’s incredibly difficult and maybe even impossible in principle to predict what inputs will help, or make any difference at all.

But the simplest example is well-described and highly reliable. Counterstimulation is a well-known method of achieving minor temporary pain relief with a sensory “distraction” from pain. It is based on the well-known neurological principle of gate control, first reported by Melzack and Wall in 196535 in which noxious sensory input is curiously pre-empted by other sensations. This is why we instinctively rub on/near acute minor injuries.

Counterstimulation is not typically a potent effect, but it’s also definitely not the only example of pain modulation. Gate control was just the tip of the iceberg of the neuromatrix: the sum of all parts of the system that produces pain as an output (after integrating many diverse inputs). Gate control is just one small outpost of the neuromatrix, “only the beginning of a continuing selection and filtering of the input.” In Melzack’s words, expanding on that point many years later:36

“The gate control theory’s most important contribution to understanding pain was its emphasis on central neural mechanisms. The theory forced the medical and biological sciences to accept the brain as an active system that filters, selects and modulates inputs. … The great challenge ahead of us is to understand brain function.”

So the question is: are there fancier and more robust kinds of counterstimulation, based on the great power of the brain to modulate pain? Probably. Melzack thought so. As early as 1981, he was publishing about how even pain gating could have a more lasting effect.37 But such benefits would be predictably unpredictable, much messier and more complex.

In principle, it seems clear that novel sensory input would be the way to chase that whole class of potential effects. If the neutromatrix is going to change its output, it needs data to integrate. And sensory data is probably the most relevant. In a sense, you could consider all of the suggestions in this article to just be variations on this theme, but the hypothesis here is that sensation is has the greatest potential to change the output of the neuromatrix.

That all sounds quite impressive, but the reality is messy and uncertain. No reason not to add “novel sensory input” to the toolkit, though, with reasonable expectations. Use any cheap, convenient, creative method you can imagine.


Fix the fixable in your life

Our major life problems are the elephant in the room, responsible for most of our stress, anxiety, and depression — which means that they also have a direct impact on how much we hurt. Of course many of those problems cannot be solved, or only with great difficulty.

But we humans also tend to be our own worst enemies, most of us aren’t quite as stuck as we think we are, and some of our worst and oldest problems probably can still be solved. There are many examples of hard life problems that can usually be fixed with hard work and a leap of faith: toxic marriages and friendships, bad jobs and bad bosses, a house or city or climate you don’t like; addictions, insomnia, and many more.

Finally taking action to fix such problems is a long and winding road to relief, and success is not guaranteed, or evidence based. It’s just too complex a strategy. But it is directly relevant in principle, and it’s not like such an effort will ever be wasted (which is lot more than you can say for most other pain treatments). For a deeper dive into this strategy, see Pain Relief from Personal Growth: Treating tough pain problems with the pursuit of emotional intelligence, life balance, and peacefulness.

I would apply the 80/20 rule to stress management: 80 percent of the stress reduction is accomplished with the first 20 percent of effort.

Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 414


Positive movement

One of the big ideas in evolutionary psychology is that our minds have many specific skills, rather than an all-purpose intelligence. If the part of the brain responsible for pain — the pain “module” — isn’t easily swayed by the part that thinks, are there other modules that might have more influence?

Probably. Todd Hargrove: “The movement modules would be first on my list.”38

“Positive movement” may be more potent than “positive thinking.” And what is positive movement? Moving as if you are more comfortable than you are: build up your confidence with whatever movement you can reasonably handle. Move in ways that are as pleasant, fun, and/or inspiring as possible. Pain limits movement — so push against those limits gently, creatively, playfully.

By the way, you can reframe several of these ideas in terms of trying a different brain “module.” For instance, the “be kind to your nervous system” advice could also be described as using the “pleasure” module to tame the pain module. And the “Create new social contexts” advice? That’s leveraging the social module — the particularly huge subdivision of our neurology dedicated to social interactions.


Don’t be a pain drama queen!

“It feels like a jagged, flaming, poisoned sword ripping through my body over and over again.”

People really talk like that, when they are in pain. My father talks like that. And I too have the impulse — genetic and/or learned — to talk like that. The apple does not fall far from the tree.

We must beware of colourful and extreme descriptions of our pain. They are tempting. There are quite a few reasons to exaggerate pain. For instance, pain is such a private experience — so often minimized or even denied by health professionals — that patients are often tempted to dramatize the pain to make it seem more real. But it’s a trap! Before you know it, you’ll believe your own story. When you exaggerate and dramatize your pain, you directly exacerbate the neurological end of the chronic pain problem. The ability to weather emotional storms — being unflappable in the first place, or recovering relatively quickly — probably affects pain levels.39

The pain scale is the imperfect replacement for flaming, poisoned swords. If you have chronic pain, you’ve probably been asked many times to rate your pain, and probably on a scale of 1 to 10, and maybe with a visual aid like this:

A typical doctor’s office pain scale chart.

On the one hand, the pain scale is an essential pain research and clinical tool, with proven value — it’s the main way that we measure the effect of therapies, to see if they really work. On the other hand, the opportunities for abusing the pain scale are legion, and the pain scale is a source of perpetual confusion in health care offices throughout the land. It sounds so easy: just rate your dang pain! But people are often stumped by the question, or they overthink it, or they wildly exaggerate.

Many times I have seen pain-scale discussions nose dive into philosophy. Is #10 reserved for the worst pain we have ever experienced, or the worst pain we can imagine? “I don't know, I can imagine quite a bit.” Can we ever really know what someone else’s pain feels like? (No.) If pain fluctuates, do we take the average? For really horrible pain do we go off the scale? Or recalibrate?

The thing is, people like to go off the scale. Drama is fun. Hyperbole is fun.

“Definitely a 15. Having a baby, yikes, that was like a 19 with spikes to 38.”

The irony is that the pain scale is supposed to help you think more objectively and rationally about your pain, but it often just creates another opportunity for melodrama. So use the pain scale, but use it wisely. Use it as a tool for getting a little more real about your pain.

Speaking of hyperbole, this pain scale business was hilariously lampooned by Allie Brosh of the brilliant, scribbly blog Hyperbole and a Half. Look back at #8 on the pain scale chart above. Does that look like a #8? According to Brosh, #8 seems to be thinking: “The ice cream I bought barely has any cookie dough chunks in it. This is not what I expected and I am disappointed.” So she did her own. Here’s her take on #8:

“I am experiencing a disturbing amount of pain. I might actually be dying. Please help.”

Now that’s more like it! No ambiguity there! Brosh’s pain scale is so funny that you will spray milk out your nose. (Assuming you drink some milk first.) Read the whole thing. But get the joke!


Limit pain talk (and the “How are you?” problem)

Never mind being a pain “drama queen,” just talking about our pain is problematic. Any kind of “pain talk” at all, even just politely answering the question “How are you?”, may exacerbate pain. Avoiding pain talk might also just be a quality of life improvement. Adira Bennet for, on answering “How Are You?”:

Every chronic illness fighter has experienced the piercing awkwardness of sharing too much with the wrong person or at the wrong time where your pal is like, ‘Oh… uh… feel better soon. I gotta go.’”

Anyone who has been in significant chronic pain for long enough knows how tiresome it gets trying to explain to people how you are doing. So you may benefit from learning not to. Tom Bowen of writes (and citing White et al):40

I recommend limiting pain talk. We can socialize without talking about pain, or worse complain about it. We are more than our pain. While pain talk can help us validate our pain, it has been shown to worsen pain. Conversely, well talk has been shown to reduce pain intensity.

I completely agree, but limiting pain talk can also be a tricky skill to learn. Finding graceful ways to answer as minimally as possible isn’t always easy. Important note: you *can* lie (“I’m fine, how are you?”) but you don’t have to. You can deftly, quickly navigate quickly to other topics, emphasizing the positive for the sake of avoiding the negative, even if feels forced and absurd to you. Remember that your pain is only the “elephant in the room” from your perspective.

There’s also a big ol’ grey zone between those times when candid conversation with good friends is truly cathartic, therapeutic, and useful… and, at the other extreme, pointless, reckless oversharing with acquaintances at the other extreme.

But learning to minimize pain talk as best you can is probably a wise course to set — and not just to reduce those awkward conversations trying to answer the dread “how are you?” question, but because it may actually help the pain. This is another great example of the indirect mind-over-pain power.


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Part 4


Related Reading

What’s new in this article?

This document has a complex editorial history, and the update log is a bit spotty and confused in places. Originally there was only one article, Pain is Weird, which covered both the “pain is an opinion” paradigm and tackle the thorny mind-over-pain implications. In mid 2021, I moved the mind-over-pain subject to its own page.

Jul 2, 2021 — Science update: Added a new sub-section… which is larger than the entire original section. Previously I made the recommendation without much explanation. This update thoroughly explores the scientific rationale. [Updated section: Change something — almost anything! — about how a painful area feels.]

Jul 2, 2021 — New strategy: Added a new sub-section explaining that cultivating ASMR (autonomous sensory meridian response) is a clear, specific, substantive way to “be kind to your nervous system.” [Updated section: Be kind to your nervous system.]

June — New section: No notes. Just a new chapter. [Updated section: Analgesic catharsis or “emotional release”.]

June — New section: No notes. Just a new chapter. [Updated section: Other approaches to mind-over-pain.]

June — New page: Most of the content for this article has been around for years, but it had outgrown its original home on the pain science page. I can give it the attention it deserves here.

Archived updates — All updates, including 11 older updates, are listed on another page.




  1. Melzack R, Katz J. Pain. Wiley Interdisciplinary Reviews: Cognitive Science. 2013;4(1):1–15. PainSci #54582 ❐

    This is just one of many possible citations for this, but it might be the best of them. The authors, my fellow Canadians Drs. Ronald Melzack and Joel Katz, have a long history of interesting research and clear writing on this topic. This is their short, technical version of the major premise for this article:

    Pain is a personal, subjective experience influenced by cultural learning, the meaning of the situation, attention, and other psychological variables. Pain processes do not begin with the stimulation of receptors. Rather, injury or disease produces neural signals that enter an active nervous system that (in the adult organism) is the substrate of past experience, culture, and a host of other environmental and personal factors. These brain processes actively participate in the selection, abstraction, and synthesis of information from the total sensory input. Pain is not simply the end product of a linear sensory transmission system; it is a dynamic process that involves continuous interactions among complex ascending and descending systems.

  2. The goal of psychological therapy for chronic pain is usually framed not as an attempt to actually treat pain directly, but to help people “live a full life with confidence in managing that pain.” (Managing chronic pain in adults) Despite that disclaimer, many a psychologist has suggested to their clients that better coping can lead to lower pain levels, which in turn makes it easier to cope. Wisely or not, mental health professionals do often aspire to treat pain indirectly via that virtuous cycle.
  3. Brodie EE, Whyte A, Niven CA. Analgesia through the looking-glass? A randomized controlled trial investigating the effect of viewing a 'virtual' limb upon phantom limb pain, sensation and movement. Eur J Pain. 2007 May;11(4):428–36. PubMed #16857400 ❐
  4. Moseley L, Gallace A, Spence C. Is mirror therapy all it is cracked up to be? Current evidence and future directions. Pain. 2008 Aug;138(1):7–10. PubMed #18621484 ❐


    Despite widespread support of mirror therapy for pain relief in the peer-reviewed, clinical and popular literature, the overwhelming majority of positive data comes from anecdotal reports, which constitute weak evidence at best. Only two well described and robust trials of mirror therapy in isolation exist, on the basis of which we conclude that mirror therapy per se, is probably no better than motor imagery for immediate pain relief, although it is arguably more interesting and might be helpful if used regularly over an extended period. Three high quality trials indicate positive results for a motor imagery program that incorporates mirror therapy, but the role of mirror therapy in the overall effects is not known. Obviously, more robust clinical trials and experimental investigations are still required. In the meantime, the relative dominance of visual input over somatosensory input suggests that mirrors might have utility in pain management and rehabilitation via multisensory interactions. Indeed, mirrors may still have their place in pain practice, but we should be open-minded as to exactly how.

  5. Fisher JP, Hassan DT, O’Connor N. Minerva. BMJ. 1995 Jan 7;310(70).

    This source is tough for readers to confirm. It’s widely cited, downright popular, because it’s a great anecdote, but of course that doesn’t mean much. Is it for real? It is indeed. If you are determined, you can verify the citation with a free trial membership for the story is just one item in the full text of the “Minerva” column, which is a compilation of snippets of interest.

  6. “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.

    And that is one of the main reasons it can be valuable to learn about all this.
  7. Parr JJ, Borsa PA, Fillingim RB, et al. Pain-related fear and catastrophizing predict pain intensity and disability independently using an induced muscle injury model. J Pain. 2012 Apr;13(4):370–8. PubMed #22424914 ❐ PainSci #54315 ❐

    The fear of pain was assessed in 126 brave volunteers with a questionnaire before — yikes — “inducing muscle injury to the shoulder.” (Don’t worry, nothing too awful for the subjects: they just did a workout with a lot of eccentric contraction that made them super sore.) The results were not what the researchers expected. This study is interesting because it found evidence that fear of pain before injury can predict recovery time. In other words: how well you respond to injury and recover is affected enough by fear that it can actually be predicted by measuring fear beforehand. That’s profound!

  8. It’s not academic hair-splitting. It doesn’t mean that pain isn’t real, or that tissues can’t genuinely be in trouble. What it means is that all pain — always, no matter what — is an unreliable interpretation of information coming to your brain from your body. Just like your brain “constructs” the reality that you see and hear and touch, it also constructs the experience of pain.
  9. [Internet]. Moseley L. Pain really is in the mind, but not in the way you think; 2013 Jul 20 [cited 14 Jan 6].
  10. [Internet]. Hargrove T. Why Your Body is a Hypocrite; 2017 September 7 [cited 17 Sep 7].

    As usual, Todd goes deep to find insight into pain science, this time mining evolutionary psychology and the modular theory of mind. (I am glad he did this reading and thinking so that I didn’t have to. Dense source material! But neat.) The article is about how different parts of your brain don’t necessarily cooperate much.

  11. Nilakantan A, Younger J, Aron A, Mackey S. Preoccupation in an early-romantic relationship predicts experimental pain relief. Pain Med. 2014 Jun;15(6):947–53. PubMed #24716721 ❐ PainSci #52835 ❐
  12. Goldstein P, Weissman-Fogel I, Shamay-Tsoory SG. The role of touch in regulating inter-partner physiological coupling during empathy for pain. Sci Rep. 2017 Jun;7(1):3252. PubMed #28607375 ❐ PainSci #53159 ❐
  13. Moseley GL, Parsons TJ, Spence C. Visual distortion of a limb modulates the pain and swelling evoked by movement. Curr Biol. 2008 Nov;18(22):R1047–8. PubMed #19036329 ❐


    The feeling that our body is ours, and is constantly there, is a fundamental aspect of self-awareness. Although it is often taken for granted, our physical self-awareness, or body image, is disrupted in many clinical conditions. One common disturbance of body image, in which one limb feels bigger than it really is, can also be induced in healthy volunteers by using local anaesthesia or cutaneous stimulation. Here we report that, in patients with chronic hand pain, magnifying their view of their own limb during movement significantly increases the pain and swelling evoked by movement. By contrast, minifying their view of the limb significantly decreases the pain and swelling evoked by movement. These results show a top-down effect of body image on body tissues, thus demonstrating that the link between body image and the tissues is bi-directional.

  14. That’s creative problem solving, but I think it only makes the impracticality point stronger: the very narrow field of view of binocs probably undermines the illusion significantly. Seeing an exaggeratedly remote looking arm through a peephole may not have the same effect. Not that it isn’t worth trying, but for this to work the brain must actually be fooled.
  15. Stanton TR, Gilpin HR, Edwards L, Moseley GL, Newport R. Illusory resizing of the painful knee is analgesic in symptomatic knee osteoarthritis. PeerJ. 2018;6:e5206. PubMed #30038863 ❐ PainSci #53038 ❐
  16. Höfle M, Hauck M, Engel AK, Senkowski D. Viewing a needle pricking a hand that you perceive as yours enhances unpleasantness of pain. Pain. 2012 May;153(5):1074–81. PubMed #22520059 ❐
  17. Toye F, Seers K, Allcock N, et al. Patients' experiences of chronic non-malignant musculoskeletal pain: a qualitative systematic review. The British Journal of General Practice. 2013 Dec;63(617):829–41. PubMed #24351499 ❐

    This paper reviewed qualitative research on musculoskeletal pain to shed light on what it’s like to have chronic pain. Several worrisome themes were clear. Chronic musculoskeletal pain often forces patients into the awkward position of having to prove the legitimacy of their condition: “if I appear ‘too sick’ or ‘not sick enough’ then no one will believe me.” Many end up doubting themselves and questioning their own identity and wondering who is “the real me.” Many lose hope and feel lost (or lost by) the health care system.

  18. For instance, it is next to impossible for impoverished single mothers of children with serious health problems and inadequate social services to support them to meaningfully “reduce stress,” and advising them to do so borders on insultingly naive paternalism.

    The realm of stress management is mostly about techniques to help deal with challenges that are less than disastrous. It is pretty effective in that sphere. But it just won’t work to generate a cult of subjectivity in which these techniques are blithely offered as a solution to the hell of a homeless street person, a refugee, someone prejudged to be one of society’s Untouchables, or a terminal cancer patient.

    Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 405

  19. Vibe-Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvåle A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. Eur J Pain. 2013 Jul;17(6):916–28. PubMed #23208945 ❐
  20. CFT patients got a 13-point boost on a 100-point disability scale, and 3 points on a 10-point pain scale. Those are not amazing results, but enough to be considered clinically significant, and they beat manual therapy and exercise handily (those patients improved by only 5.5 and 1.5 points on the same scales).
  21. “Promising” is a badly abused word in modern science. I have gotten extremely fed up with “promising” research, because it’s almost always exactly the opposite: just a pathetically weak signal p-hacked out of a bunch of noise and spun into something worthy of a press release.

    Meme of Inogo Montoya with caption: “Promising. You keep using that word. I do not think it means what you think it means.”

    And so I use the word myself with great caution. In this case, however, the effect size is actually clinically significant — not just statistically significant, an important difference. It still needs replication, but unlike the vast majority of “promising” results, it actually has a fair to middlin’ chance of being replicated.

  22. Moseley GL. Whole of community pain education for back pain. Why does first-line care get almost no attention and what exactly are we waiting for? Br J Sports Med. 2018 Jul. PubMed #29982226 ❐

    Dr. Moseley makes the case for back pain education, and it’s quite inspiring:

    Contemporary pain education is potentially more powerful for persistent pain than drugs and as powerful as anything else we can offer. Education is a missing link that would actually make advice to be active, to exercise and to consider psychological therapy a sensible strategy for back pain. Research shows that when someone with persisting pain begins to understand their pain, they actually engage in active, psychologically informed strategies and can have drastic reductions in pain and disability over the next 12 months; for these people, recovery is back on the table.

    Truly excellent outcomes are possible for those persistent pain sufferers who take on the journey of retraining their overprotective pain system to be less protective. Contemporary pain science offers compelling reasons to suggest that recovery is within the realms of possible for many persistent pain sufferers. There is genuine hope—not for a quick fix but for a pathway to gradual recovery. It is not for the faint hearted, but people with persistent pain seldom have faint hearts.

  23. Schultz IZ, Crook J, Meloche GR, Berkowitz J, et al. Psychosocial factors predictive of occupational low back disability: towards development of a return-to-work model. Pain. 2004 Jan:77–85. PubMed #14715392 ❐

    This study identified factors affecting return-to-work time after an episode of low-back pain. From the abstract: “The key psychosocial predictors identified were expectations of recovery and perception of health change.”

  24. Brison RJ, Hartling L, Dostaler S. A randomized controlled trial of an educational intervention to prevent the chronic pain of whiplash associated disorders following rear-end motor vehicle collisions. Spine. 2005 Aug 15;30(16):1799–807. PubMed #16103847 ❐

    This is one of a few studies showing a benefit to education for neck pain specifically. Researchers showed a reassuring educational video to more than 200 patients with “whiplash associated disorders” (i.e. whiplash injuries that become chronic neck cricks), and found that they had less severe symptoms than patients who received no educational intervention. The effectiveness of education probably depends a lot on the type of neck pain and the type of education, making it very hard to study. A recent review of the scientific literature found that most such studies are negative (see Haines or Ainpradub), but I believe that there are still reasons to be optimistic about education for pain problems. Above all, it depends on the type and quality of the education! The right education may be effective, and the wrong could even be harmful. The fact that some education has been shown to be beneficial is promising.

  25. [Internet]. Moseley L. The therapy might work, but does it work in the manner you think it does?; 2012 Jun 18 [cited 15 Jul 15].

    We know that “explaining pain” seems to reduce it, but how? Do we really know what’s going on? “The theory behind explaining pain is that it decreases pain by changing the underlying schema about what pain actually is.” Dr. Moseley methodically applies a validity test to that theory, which it passes with flying colours, meaning that it is a reasonable, working theory about how pain education works (not proof that is does work — a technical but important difference).

    For contrast, note that in a follow-up article, he concludes that graded motor imagery does not satisfy the burns test — a nice demonstration of the integrity of his reasoning.

  26. Overuse of MRI and X-ray for back pain is an over-medicalization disaster, criticized for decades for generating way too many false alarms. Low back pain is extremely multifactorial, and the spinal glitches that imaging reveals are just one ingredient in a rich stew of risk factors, and often a minor one. Spinal degeneration is shown by MRI in many asymptomatic people. Diagnosis based mainly on imaging is almost always misleading and unnecessarily spooks patients, doing real harm through the power of nocebo (placebo’s evil twin). There are also huge quality control problems with MRI. It should be use minimally, only when strongly indicated by persistent major symptoms. Patients should refuse early MRI and take radiology reports with a huge grain of salt. See MRI and X-Ray Often Worse than Useless for Back Pain: Medical guidelines “strongly” discourage the use of MRI and X-ray in diagnosing low back pain, because they produce so many false alarms.
  27. Not all quackery is obvious — not even to skeptics. “Pseudo-quackery” appears to be mainstream, advanced, technological, “science-y,” or otherwise legit — quackery without any sign of being way out in left field. It has enough superficial plausibility to persist in the absence of evidence against it. This subtler type of snake oil is a more serious problem in musculoskeletal health care, because it hides right in the mainstream. For instance, it’s nearly synonymous with the early history of physical therapy, and remains alarmingly prevalent in that profession. So pseudo-quackery is extremely common, and generates more false hopes and wasted time, energy, money, and harm than more overt quackery, which is relatively marginalized. See Pseudo-Quackery in the Treatment of Pain: The large, dangerous grey zone between evidence-based care and overt quackery in musculoskeletal and pain medicine.
  28. It’s not an accident that chiropractors diagnose spinal subluxations, and massage therapists diagnose tight muscles, and naturopaths diagnose “imbalances” to be corrected with elaborate regimens of supplements, and so on.

    I was a “freelance therapist” for a decade — a massage therapist in private practice — so I have good direct experience with the economic pressures. I am an enterpreneur, and I don’t think it’s inherently wrong to charge fees to help and educate people (some people actually do believe that) but obviously a financial motive can be highly corrosive to professional integrity. It is every health care professional’s highest ethical responsibility not to confuse profitable recommendations with good health care. They are rarely the same thing.

  29. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott Williams & Wilkins; 2000.
  30. Apkarian AV, Baliki MN, Farmer MA. Predicting transition to chronic pain. Curr Opin Neurol. 2013 Aug;26(4):360–7. PubMed #23823463 ❐ PainSci #53165 ❐

    The gist of this complex paper is that the brain’s anatomic and functional properties predict development of chronic pain, and correlate with emotional state. It’s not necessarily correct, but it’s certainly interesting! It’s important to note that Apkarian is associated with some other particularly bad research (see Vachon-Presseau 2018).

    As always, Todd Hargrove does an admirable job explaining research like this: see "To Predict Chronic Pain, Look to the Brain."

  31. These are truly effective drugs, but that also makes them dangerous: the risk of addiction is real, and withdrawal can be a devastating experience (think “anxiety on steroids”). The only truly safe way to use benzos is temporarily. For much more information, see A Story of Benzodiazapene Withdrawal Gone Horribly Wrong.
  32. Collins, Sean T. "[Why music gives you the chills](". BuzzFeed. September 10, 2012. Retrieved Jul 2, 2021.
  33. Stephens R, Atkins J, Kingston A. Swearing as a response to pain. Neuroreport. 2009 Aug;20(12):1056–60. PubMed #19590391 ❐
  34. Obviously bracing a knee with a ruptured ligament is a different case, and straighforward. Similarly, you can certainly tape up a sprained ankle for pure stability — not a sensory effect. But bracing is often prescribed for much less clear reasons, and taping gets even weirder, like the absurd colourful tape that was so faddish in the 2011 Summer Olympics. These approaches to rehab often have wildly speculative rationales, when most likely they are all just creative ways of changing sensation.
  35. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965 Nov;150(3699):971–9. PubMed #5320816 ❐

    This is Melzack and Wall’s seminal paper arguing that (emphasis mine) “pain perception and response is triggered after the cutaneous sensory input has been modulated by both sensory feedback mechanisms and the influences of the central nervous system. We propose that the abstraction of information at the first synapse may mark only the beginning of a continuing selection and filtering of the input.” Among other things, this is the paper that described the mechanism of gate control and ultimately gave rise to the highly influential concept of the neuromatrix (Melzack).

  36. Melzack R. From the gate to the neuromatrix. Pain. 1999 Aug;Suppl 6:S121–6. PubMed #10491980 ❐
  37. Melzack R. Myofascial trigger points: relation to acupuncture and mechanisms of pain. Arch Phys Med Rehabil. 1981 Mar;62(3):114–7. PubMed #6972204 ❐
  38. Hargrove 2017, op. cit. I’m paraphrasing and riffing off of Todd’s thinking here — almost just a synposis of his idea, really.
  39. Ruiz-Aranda D, Salguero JM, Fernández-Berrocal P. Emotional Regulation and Acute Pain Perception in Women. J Pain. 2010 Jun;11(6):564–569. PubMed #20015703 ❐ Two groups of women were tested for pain tolerance with the traditional, unpleasant method (immersion of the hands in ice water). One group was rated with better emotional coping skills, and (predictably) they were more tolerant of pain than women with poorer coping skills.
  40. White B, Sanders SH. The influence on patients' pain intensity ratings of antecedent reinforcement of pain talk or well talk. J Behav Ther Exp Psychiatry. 1986 Sep;17(3):155–9. PubMed #3760222 ❐


    This study sought to determine whether positive verbal reinforcement for pain talk or well talk could effectively influence chronic pain patients' subsequent ratings of pain intensity. Four female chronic pain inpatients were each exposed over seven consecutive days to two conditions within an alternating treatments design. Inter-rater reliability analysis from the audiotapes on occurrences of pain and well talk, verbal reinforcement and appropriate reinforcement of verbal behavior across conditions resulted in agreement values from 91 to 100%. Findings revealed that subjects' pain intensity ratings were consistently and significantly lower after verbally reinforcing well talk compared with verbally reinforcing pain talk.