Painful Lessons
What I’ve learned from twenty-five years of studying pain and injury

This is a collection of some of the major lessons acquired in my 25 career trying to help people — and myself — with chronic pain and stubborn injury rehab challenges. It is quite conservative.
I cringe when I think back on my first several years as a massage therapist, selling myself to patients as a chronic pain troubleshooter. I knew less than John Snow, less than nothing — my mind was cluttered with simplistic misconceptions that I had to actively clean up over the years. It was a good example of how ignorance is less the absence of knowledge, and more the illusion of it, like a cuckoo bird laying its own eggs in other bird’s nests.
I started in 1997. I didn’t understand most of what's described here until at least 2010 — when I retired from massage therapy (somewhat dramatically) after a decade of clinical practice.
Everything listed here today is something that I am now fairly sure of, the major concepts I now more or less take for granted after twenty years of constantly investigating the legitimacy of popular ideas about treating painful problems. The highest certainty, and the greatest importance.
Some disclaimers
I will not defend any of these points in any detail here (though I do link to more information in most cases). There are, of course, lots of caveats. The devil is always in the details. For now, this list is incomplete and relatively glib. Just how confident am I in these things? Not extremely — but that's because the single most important lesson I’ve ever learned about pain is that it’s too complicated to ever be really sure of anything. All knowledge is provisional, and knowledge about pain is especially provisional! But what confidence I do have about each of these things has fairly deep roots. The sun will probably come up tomorrow, and I am just as likely to believe these things in five years. (And if I’m wrong about that, I can’t wait to find out how.)
The lessons
- Chronic pain is weird, a function of many known and unknown variables, and its peculiarities and volatility can become more important than whatever started it. That is, pain can be a lot like a disease unto itself. So are our many non-specific vulnerabilities to pain, like sleep deprivation, chronic stress, poor fitness, and so on.
- Sensitization, the pathological amplification of nociception and/or perception, isn’t just one of the most important but least-respected factors in chronic pain, it’s practically synonymous with it. There are many paths to sensitization, but it’s present in virtually all serious cases of chronic pain (regardless of whether or not there’s on-going nociception).
- Biology is destiny. A lot of pain is a symptom of obscure, hard-to-diagnose medical problems. For every obvious cause of pain, there are a dozen that are much trickier. Rare conditions are individually rare, but collectively common. A failure to diagnose a clear biological cause of pain does not mean there isn’t one, and in general patients with stubborn unexplained pain should not give up hope of someday finding an explanation. See 38 Surprising Causes of Pain.
- Biochemistry is much more important than either of the two big simplistic bogeymen of pain and injury: biomechanics and psychology. Pain is mainly a function of complex and messy physiology, especially nearly and immunology (because inflammation). This is not to say that things like anxiety or ergonomics are entirely irrelevant to pain, but they dominate the field because we have been “looking where the light is,” thinking about how pain works in terms of things are relatively easy to literally see (posture) or imagine (stress). The reality is that we’re never going to truly understand how most chronic pain works, and therefore how to treat it, without coming to grips with much subtler physiology.
- “Fibromyalgia” is not a specific condition: it’s just a label for unexplained chronic widespread pain, which has many possible explanations. Also, the longer I have studied (and endure) chronic pain and illness myself, the more convinced I have become that chronic fatigue syndrome and fibromyalgia have a great deal in common.
- “Nothing works”: not one single manual or passive therapy has ever been shown to have an unambiguous, impressive effect on tissue state or rehabilitation for the average patient. Most “positive” and evidence for treatments is no such thing: it usually just damns them with faint praise. Statistically significant but clinically trivial effects — minor and short term — can be scientifically demonstrated for nearly any treatment, because therapeutic interactions are very complex and drive a lot of expectation effects, and transient descending modulation. Thus we have endless “promising” results for treatments that never amount to much. I have written about what works as well as I can, but there is exasperatingly little to write about.
- Trying to be as fit and healthy as possible is usually by far the most useful thing anyone with chronic pain can do. While it is far from guaranteed to solve anything, you can't really go wrong trying (respecting whatever limitations you have, of course). Vulnerability to pain due to physiological stresses like sleep deprivation or smoking is often just as important as specific causes of pain, whatever they might be. See Vulnerability to Chronic Pain: Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems.
- “No pain, no gain” has immense influence. It is one of the most pervasive and toxic ideas in the world of therapy and rehab. While it is true that some discomfort is necessary for adaptation, “what doesn’t kill you” does not always make us stronger.
- The science is a mess. More broadly speaking, it’s shocking how primitive musculoskeletal and pain medicine still are. The majority of scientific trials in the field are junky and incompetent, incapable of actually moving the field forward, doomed from the start by small sample sizes and seriously flawed methods. Some of the junk is well-intentioned but underfunded, but a lot of it is clearly a "token effort" that exists largely to pad someone's resume. But it gets worse! A disturbingly high percentage of papers have more serious problems: egregious pseudoscience, not actually peer-reviewed (predatory journals), actually fraudulent. See 14 Kinds of Bogus Citations, Studying the Pain Studies, and A Historical Perspective On Aches ‘n’ Pains.
- Quackery, crankery, and grifting are standard for chronic pain/injury treatment, not the exception. Most people have no reason to suspect how bad it is, and naturally assume that healthcare for chronic pain and injury is relatively advanced and mainstream. The tragic reality is that almost every treatment idea out there exists because it is simplistic and emotionally appealing enough to be marketable and literally just seems more advanced than it actually is. Nearly every methods and product is the product of decades of aggressive self-promotion by entrepreneurial clinicians trying to make a living … or get downright rich, usually by selling “certification” in their methods to other healthcare professionals. The field is dominated by the “modality empires” — proprietary method (mode) of therapy championed by a charismatic and entrepreneurial founder (the emperor), selling books, workshops, and/or certifications. If you’ve heard of a branded method, it’s because it is one of the commercial survivors — and it is defined and shaped by its ability to compete in that marketplace, not by its medical efficacy. For the more detailed version of this rant, see: You’ve only heard of marketable pain treatments.
- Not all quackery is obvious. “Pseudo-quackery” is quackery that passes for good medicine despite strong evidence that it doesn’t work. Unfortunately, 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. Probably the best single example pseudo-quackery is ultrasound and shockwave therapy.
- Surgery is the ultimate placebo. Most common orthopedic surgeries are based on tradition, authority, and the faith and “common sense” of surgeons. Many have never been properly tested in a well-designed clinical trials, or only surprisingly recently. Most of those that have been tested any could not outperform placebo, and many more will probably fail in the future. •mind blown•
- Stretching is the king of popular-but-useless self-treatments. Practically everyone thinks they should stretch, but it’s mostly a waste of time that doesn’t do anything people hope it does, other than feel good. It deserves less than 5% of its popularity and should not be considered a pillar of fitness, equal in status to strengthening or aerobic exercise. It doesn't hold a candle to those, or good nutrition, or sleep.
- Regenerative medicine will probably amount to something someday, but it’s all hype and broken promises so far, for many years. We know that regeneration is biologically possible in principle from a few very cool animals that can do it, but it is the fusion reactor of medicine: ten years in the future for several decades now. Nothing at all that claims to “accelerate” healing is ready for prime time (e.g. platelet-rich plasma, cartilage regeneration, photobiomodulation, and so on).
“In my experience” are the most dangerous words in medicine (Crislip). The value of clinical experience is extremely over-rated by many if not most clinicians. Trusting your own anecdata too much is deeply at odds with science and evidence, and it’s a truly terrible way to figure out what actually works. “Success rates” are not something individual clinicians can ever actually know, and it wouldn’t constitute validation of methodology even if they could. Clinical outcomes are affected by a dazzling number of confounding factors, but one in particular: clinicians have a badly skewed sample, because patients are much more likely to tell them about successes than failures, and even the so-called successes are often exaggerated or optimistically delusional. I explore this in more detail using dry needling as an ideal example.
Clinicians don’t just underestimate these problems; as a group, they are aggressively ignorant of them.
- Posture is by far the most over-rated factor in chronic pain, and the preoccupation with posture in the manual therapies is the most glaring sign of the amateurishness of those professions. Any therapist who starts a session with a “postural scan” should be fired. See Does Posture Matter?
- Not all chiropractors are ignorant jerks … but way too many of them are. There are definitely bad apples in every profession, but chiropractic is more like a barrel full of rotten apples with just a handful of good ones — and it’s nearly impossible for patients to tell the difference. In 1999, I was still willing to give the average chiropractor the benefit of the doubt, but that declined steadily for years and was pretty much gone by 2010.
- I am definitely on Team Skeptic, but skepticism can be reflexive and shallow, and I wish some skeptics would get off my team, because they are just as emotionally/socially toxic as anyone on Team Pseudoscience. More specifically, I have learned that skeptics can get mired in precisely the same kinds of thinking mistakes as the cranks and quacks they criticize. When I first became a “card-carrying” skeptic around 2009, I was only abstractly aware of the idea a basic tenet of skepticism was that it was important to realize that skeptics suffer from the exact same cognitive distortions as all other humans. I have since learned that this is not a minor academic consideration. The reality is harsh: skeptics can and do get seriously blinkered by massive confirmation bias (among other things). And so I think there are a lot of clumsy, half-arsed skeptics out there, especially in the community of manual therapists who figure they are enlightened because they have figured out that homeopathy is ridiculous and how to shout “Dunning-Kruger effect” at roughly appropriate moments in online arguments. 🙂
- Resistance training — building strength by lifting heavy things over and over again — is a more useful, easier, more efficient, and valuable part of both fitness and rehab than I ever would have dreamed 20 years ago. This is true even for people who have no interest in gyms, and most people are more than capable of doing a good job with minimal coaching or training. “Advanced” knowledge and technique aren’t better, or even needed at all for most progression, rehab, or “corrective” goals. The world of training and strength and conditioning almost comically inflated with advice and wisdom that is superfulous, ridiculous, and redundant. At best, it’s fine but tends to offer sharply diminishing returns beyond anything you couldn’t cram into a good pamphlet (certainly for anyone who isn’t a bodybuilder or serious strength athlete, and maybe even for them). At worst, it’s just an awful lot of amateurish delusion and influencer-garbage. The major example of this is that there are a dizzying number of branded ideas and factions dedicated to the “best” way to optimize training for strength and/or hypertrophy, and yet the evidence is overwhelming that there are no more important differences between any of them. The industry has had a love affair with technique optimization for decades now without any real results. If you’re wearing out your muscles regularly and safely for you, it’ll work quite well.
- Most rehab from injury basically boils down to calming shit down, and then building shit up. You can boil that down even more to just “load management.” The reason it’s tricky is that there are all kinds of unknowable variables that affect our load tolerance at any given point in the process. Also, many people underestimate the taking-it-easy part, and pushes too hard, too soon for the getting-back-to-normal part — often encouraged by the exuberant, no-pain-no-gain style that is particularly prevalent in North American physical therapy, exercise, and sports. See The Art of Rest.
- “Post-massage soreness and malaise” happens more often and worse than I ever would have dreamed (or dared to imagine) when I was working as a massage therapist. I cannot know the real prevalence, but after years of email from alarmed massage clients around the world, it is clearly a bit of a thing. See Poisoned by Massage.
- The “power” of placebo is badly misunderstood and chronically overstated. Placebo is fascinating, but its “power” isn’t all it’s cracked up to be: the power of belief is strictly limited and accounts for only some of what we think of as “the” placebo effect. There are no mentally-mediated healing miracles. But there is an awful lot of ideologically motivated hype about placebo
- The controversy over the nature of trigger points is a legitimate, ongoing scientific controversy. It should not be a closed topic, as argued by some critics: that is an unsupportable extreme in my opinion. Humble, conservative trigger point therapy is justified and ethical, if presented as an experimental treatment.
Also, the nervous system is high performance, but also just a bit glitchy, prone to lots of subtle screw-ups, many of them inconsequential, but clearly not all. This accounts for a large percentage of puzzling pain and odd sensations, a perverse randomness that is jarringly at odds with everyone’s assumption that every pain must have a singular cause. Certainly it can.
About Paul Ingraham

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:
What’s new in this article?
Mar 3, 2024 — Added two new items: “Pain is mainly a function of complex and messy physiology,” and “Quackery and crankery is the rule for chronic pain treatment, not the exception.” Elaborated on “the science is a mess.”
2024 — Added more thoughts about how skepticism goes wrong, and the accessibility and importance of resistance training.
2019 — Publication.