• Good advice for aches, pains & injuries

Vulnerability to Chronic Pain

Chronic pain often has more to do with general biological vulnerabilities than specific tissue problems

Paul Ingraham, updated

Many major causes of chronic pain do not entirely or directly do their dirty work, not a tidy B-follows-A cause and effect relationship. Instead, some of the worst causes are the general conditions in which pain flourishes, the soils and fertilizers it likes.

For instance, if the same minor structural problem with the spine can cause a lot of pain in some people, but only trivial or no pain at at all in many others, then is it really a “spine” problem? The more basic issue is the underlying vulnerability to any kind pain, which increases the risk of a minor glitch blooming into a chronic pain problem.

Which may be the case with most spinal pain, by the way. Structural problems in the spine are seriously over-rated as causes of neck pain and back pain.

And what are these general vulnerabilities? Consider sleep deprivation: everything hurts more when you lose too much sleep. See below for a complete list of the usual suspects, both biological and psychological. Many of them are not the kinds of things we’re used to thinking of as the causes of a specific body pain. When we hurt, we don’t just assume there is something wrong, but something specific: strained or damaged tissues.

But it may not be specific! Or it may be effectively impossible to diagnose, or it could be a general vulnerability to pain. Once you’re vulnerable, practically any specific problem can become a new source of torment, without really being the real problem. Fighting causes like this feels like boxing with smoke, but may still represent the biggest opportunity to treat stubborn chronic pain.

It is more important to know what sort of person has a disease than to know what sort of disease a person has.

~ Hippocrates

I believe that this is a large part of the chronic pain puzzle: it’s not just that specific causes are often hard to find, it’s also that they are not alone. And in many cases of chronic widespread pain (“fibromyalgia”), non-specific vulnerabilities might be the whole story.

The usual suspects: the classic, non-specific, modifiable risk factors for chronic pain

There are several common modifiable risk factors for any kind of chronic pain that are typically neglected. Notice that they overlap extensively with misfortune, a hard life, and being out of shape.

These are all things you can change, in theory. With great difficulty, perhaps, but it’s possible. (I’ve left out pathologies and genetic vulnerabilities that boost systemic sensitivity — that’s a whole ‘nother can of worms, which I open elsewhere, see 34 Surprising Causes of Pain).

If you’re suffering from any kind of chronic pain, it may make more sense to work on these bigger picture issues than it does to try to chase down specific causes. It’s difficult, of course. The big factors are often thoroughly entangled, all making each other worse. An impoverished single mom with a nasty ex husband, a nicotine addiction, and diabetes looming is going to have more than just a “tough time” digging her way out of that mess. And yet it still be the closest thing to real hope of a cure from a serious chronic pain that has been driving her nuts.

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

Why do these things make us hurt?

Because pain is weird. There are a lot of false alarms. The pain system is basically a threat detection system — all pain is, in theory, warning you about something. What is worthy of a warning is strongly affected by the brain’s “opinion” of how much danger we are in. All of these things lower our brain’s threshold of concern, the level at a give tissue threat is enough to worry our brains. When the threshold is lowered far enough for long enough, you have have entered the strange and terrible land of central sensitization, a disease of having too many false alarms, and too loud. “Sensitization” is probably the main mechanism by which things like sleep deprivation make us hurt more.

But central sensitization is a separate topic, and there are definitely other ways that these general problems can result in specific chronic pain.

Another major mechanism, for instance, is probably systemic inflammation, which results in more intense and persistent signals from tissues. How much does a toe stub hurt? How many nerve impulses are sent to the brain? Well, definitely more if you are a little bit inflamed everywhere.

Vulnerability reduction projects, AKA “lifestyle medicine”: not easy, but simple

When the primary complaint is pain, the treatment of pain should be primary.

~ Barrett Dorko, Physical Therapist, online discussion, 2010

How do you reduce a general vulnerability to pain? It’s one of those things that is simple in principle, but not at all easy: if you really want to solve your chronic pain problem, then start making yourself as healthy as possible overall. Which is huge. Like any difficult, complex problem, you break it up into pieces and start with the easiest bits. It’s a long-term “pick your battles” challenge. More exercise and sleep deprivation are usually the lowest hanging fruit, and I make a few other suggestions, roughly in order of priority. And I recommend tackling these one at a time.

These aren’t “treatments” per se because one of these approaches is known to be good for any specific condition — except, perhaps, heart disease. However, they can be considered “anti-inflammatory” to a significant degree, because chronic low-grade inflammation is nearly synonymous with being out of shape and an unhealthy lifestyle.

Warning! The advice below is going to seem general to the point of being trite and useless, but that’s actually the point. Chronic pain patients understandably want specific answers, not vague platitudes, not pep talks. But the point of this article is that “general answers” probably actually do matter, a lot.

Get more exercise

If you are badly out of shape, you could literally spend a decade learning how to be a more active and fit person. But you can start walking more tomorrow… and you can’t make a better, simpler investment in your health than just turning that dial a little bit. Do that first, get used to it, and then consider what comes next. Working up a sweat isn’t required, but five to ten minutes of it per day is a big upgrade from just walking — the returns start to diminish after that. Note that pumping a little iron offers incredible bang for buck and is by far the most underestimated and neglected exercise option among people who are gym-shy. Further reading:

Also, exercise is notably helpful with every other approach discussed here. For instance, it’s a critical way to help get more sleep…

Get more sleep

This is often a great place to start because it’s so common and so often an “unforced error,” caused entirely by poor “sleep hygiene” — the cumulative effects of many little things that disturb sleep. It’s even more important to work on sleep hygiene even when it’s not the main problem, like for people with sleep disorders, like sleep apnea, which are shockingly common. The more trouble you have with factors you cannot control, the more important it is not to neglect the factors you can control. See The Insomnia Guide: Serious insomnia-fighting advice from a veteran of the sleep wars.

Get less smoke

Quitting smoking has the biggest payoff of any clearly defined self-improvement project for patients with chronic pain. There is strong evidence that smoking is a major aggravating factor in chronic pain12 Smoking may partly explain why back pain becomes chronic in some people,3 and so likely neck pain as well.

Quitting is also the simplest thing on this list that you can tackle. But simple is not the same as easy, of course, and beating a nicotine addiction is incredibly difficult for many people — so stressful that it can interfere with everything else. On the other hand, not everyone finds it crazy hard to get rid of nicotine. Advice on smoking cessation is out of the scope of this website. But I have written about its relevance to chronic pain, which may help to inspire you: see Smoking and Chronic Pain: We often underestimate the power of (tobacco) smoking to make things hurt more and longer.

Eat an anti-inflammatory diet

… which is mainly just a non-stupid diet that isn’t obviously hurtling you towards obesity, heart disease, and diabetes (metabolic syndrome). No one knows exactly what a non-stupid diet is, but we know it when we see it, because it’s obviously characterized by moderation, and you don’t eat like a teenager. The booze is minimal, the portions are rarely super-sized, you drink more water than soft drinks, there’s not much deep fried, and very little of the food is fast. It’s not about superfoods or antioxidants or supplements or “paleo.” This self-improvement project is a lot harder than it sounds, and it’s very unclear how much it will help with any chronic pain proble. But the best thing about it? You cannot waste your time on this: it’s worth doing even if it has exactly zero effect on whatever specific pain problem you have.

Or you could try not eating: fasting as an anti-inflammatory diet

The most anti-inflammatory diet of all could be intermittent fasting — regularly skipping some meals basically — which induces some interesting metabolic changes that might contribute significantly to overall health,4 in part by reducing systemic inflammation.5 It’s suspiciously trendy and unproven,6 but also plausible, practical, and reasonable, and perfectly good as a weight-loss diet if nothing else. See Chronic, Subtle, Systemic Inflammation for a more in-depth analysis.

And again, it may not be that fasting is anti-inflammatory, but rather that long-term overeating is inflammatory.


This is probably the most useless-but-important advice I ever give on Stress reduction is probably the ultimate in “easier said than done” challenges. It truly matters, but the things that cause stress are often totally out of our control, or insanely difficult to control. If they weren’t, they wouldn’t be serious sources of stress in the first place.

For instance, a career change might be your only real hope of significantly reducing stress in your life… which might require going back to school, which you can’t afford… and so on. This challenge needs to be subdivided into smaller challenges. For more ideas, see Anxiety & Chronic Pain: A self-help guide for people who worry and hurt. And don’t get hung up on yoga and meditation. Reducing stress is mostly about doing your best to solve life problems, not about trying to transcend them. And exercise, while not a perfect solution for everyone, is almost certainly the best overall single medicine for stress and anxiety (and much else).78

The biology of vulnerability to depression is that you don’t recover from stressors very well.

~ Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 307

Make more friends

Social isolation, AKA “loneliness” for those who are unhappy with being isolated,9 is a major general health suppressor in the same league as anxiety and chronic stress, sedentariness, smoking, sleep deprivation, and metabolic syndrome.10 It almost certainly involves increased vulnerability to chronic pain as part of the deal, and some evidence definitely suggests this.11 We do know that sensitization and pain chronicity are driven by catastrophization and social factors, and injury and disability are always going to be more of a threat — more “catastrophic” — to people without good social support, or the opportunity to be supportive. Giving support is just as stress-relieving as getting it. In other words, you have more to worry about and less to do when you’re lonely.

Obviously it can be tough to get out there and interact with new people. It could even more more stressful at first.12 The effort might make loneliness worse — or feel worse — before it gets better, because loneliness is hardest to escape for the people who need it the most. But it’s a worthwhile investment.

If you’re so isolated and lonely that improvement feels truly impossible, it might be time to get some professional help with that. And if that feels impossible or unaffordable, then tackle it the only way anyone ever solves a tough problem: baby steps! Pick the easiest way of getting more social contact that you can possibly imagine, and start there.

Make more money

Money does not buy happiness, but perceived poverty is crazy stressful. Why “perceived”? Because we don’t really care how much money we have — we care how much everyone else has. It’s not our absolute level of affluence that concerns us, but how affluent we are compared to the rich bastards all around us. It’s feeling like we are on the outside of something good, enviously looking in, that really eats away at our happiness.

The best defense is a good offense: to whatever extent possible, get better at the rat race. Or move somewhere a lot cheaper.

Easier said than done

Collectively, tackling all of this would constitute a total personal makeover. You could spend the rest of your life working on it, just growing up and trying to be a better person overall, and who knows if any of it is actually going to change your chronic pain — tragically, it might not, because there are many, many causes of pain.

Or maybe your pain will finally go away, but you’ll never know if it was because you finally started eating better and working out a little more.

But if we could somehow compare a thousand people with pain who really made a sincere effort to increase their overall immunity to chronic pain, to a thousand who didn’t… I know which group I am betting on.

The best evidence for treating persistent pain points towards improving general health, as opposed to fixing specific “issues in the tissues.”

~ Playing With Movement, by Todd Hargrove, p. 217

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

What’s new in this article?

JanuaryAdded some quotes and context from Sapolsky on the stresses of combatting loneliness, and the intractability of severe stresses.

Related Reading

Around the web…


  1. Choi CJ, Knutsen R, Oda K, Fraser GE, Knutsen SF. The association between incident self-reported fibromyalgia and nonpsychiatric factors: 25-years follow-up of the Adventist Health Study. J Pain. 2010 Oct;11(10):994–1003. PubMed #20400378.  More smokers have fibromyalgia than non-smokers. The difference was statistically significant in a survey of more than 3000 women.
  2. Behrend C, Prasarn M, Coyne E, et al. Smoking Cessation Related to Improved Patient-Reported Pain Scores Following Spinal Care. J Bone Joint Surg Am. 2012 Dec 5;94(23):2161–6. PubMed #23095839. 

    This study added to the pile of evidence that smoking is “associated with low back pain, intervertebral disc disease” along with many other medical complications. Their conclusion, after studying the records of more than 5000 patients with “axial or radicular pain from a spinal disorder,” was that there is a “need for smoking cessation programs for patients with a painful spinal disorder.” Very likely both neck and back, of course.

  3. Petre B, Torbey S, Griffith JW, et al. Smoking increases risk of pain chronification through shared corticostriatal circuitry. Human brain mapping. 2014 Oct. PubMed #25307796. 

    The science here is a bit more complex than I usually deal with, but the punchline is simple enough: “We conclude that smoking increases risk of transitioning to chronic back pain.”

  4. de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019 12;381(26):2541–2551. PubMed #31881139. 
  5. Jordan S, Tung N, Casanova-Acebes M, et al. Dietary Intake Regulates the Circulating Inflammatory Monocyte Pool. Cell. 2019 Aug;178(5):1102–1114.e17. PubMed #31442403. 
  6. The “growing body of evidence” has been exaggerated by everyone (surprise surprise), and fasting has not yet been shown to be “anti-inflammatory” per se. As of early 2020, there is quite literally only one good modern study showing clear evidence of an anti-inflammatory effect in humans. Nevertheless, there is a lot of indirect evidence, things like animal and cellular research, and some evidence that fasting improves autoimmune diseases.
  7. Schuch FB, Stubbs B, Meyer J, et al. Physical activity protects from incident anxiety: A meta-analysis of prospective cohort studies. Depress Anxiety. 2019 Jun. PubMed #31209958. 

    This meta-analysis links high levels of activity to lower rates of anxiety. Many people who exercise will still develop anxiety, but 26% less often than sedentary people. The authors focused on 13 studies with “moderate to high methodological quality and a low risk of bias” with a huge total sample size of 76,000 people, and they made adjustments to eliminate the effect of gender, BMI, and smoking (in other words, they tried to make sure that observed effects were actually due to the activity level, and not those factors).

    The simple headline “exercise helps anxiety” could describe the results of this study, but as usual the details are devilish, and it’s actually not such a clear win. With such a huge pool of data to play in, the authors decided to break it down into several different types of anxiety, and found that the results were statistically significant only for PTSD and agoraphobia… and not generalized anxiety and a few others. Although activity seemed to help all types of anxiety, there was not actually enough data here to be sure in most cases — a data pie of 76,000 subjects seems big, but it can easily be sliced into pieces too thin to trust. It’s likely that exercise does help most types of anxiety, but it’s hard to actually know it from this data.

    And this is why science is slow to be sure of much of anything squishy and complicated.

  8. Pedersen BK, Saltin B. Exercise as medicine - evidence for prescribing exercise as therapy in 26 different chronic diseases. Scand J Med Sci Sports. 2015 Dec;25 Suppl 3:1–72. PubMed #26606383. 

    This is s a roundup of evidence and prescription guidelines for prescribing exercise for many (26!) different diseases, which is not to say that the science is necessarily complete and perfect. Consider the nuance in Schuch, which found good overall evidence that exercise protects people from “anxiety,” but — despite a huge sample size — could only actually report statistically significant results for a couple specific types (PTSD and agoraphobia). So does exercise work for anxiety? Likely, but “it’s complicated,” as always.

    Still, it’s hard not to be impressed by the sheer volume and diversity of the evidence inspiring these authors.

  9. “Lonely” is a negative emotion by definition, but not everyone is unhappy about being socially isolated. A “loner” might be just fine with their social isolation.
  10. Sapolsky RM. Why Zebras Don’t Get Ulcers. 3rd ed ed. New York: Times Books; 2004. p. 164. “…the fewer social relationships a person has, the shorter his or her life expectancy, and the worse the impact of various infectious diseases. Relationships that are medically protective can take the form of marriage, contact with friends and extended family, church membership, or other group affiliations. This is a fairly consistent pattern that cuts across a lot of different settings. Moreover, these general findings are based on some careful prospective studies and are seen in both sexes and in different races, in American and European populations living in both urban and rural areas. Most important, this effect is big. The impact of social relationships on life expectancy appears to be at least as large as that of variables such as cigarette smoking, hypertension, obesity, and level of physical activity.
  11. Smith TO, Dainty JR, Williamson E, Martin KR. Association between musculoskeletal pain with social isolation and loneliness: analysis of the English Longitudinal Study of Ageing. Br J Pain. 2019 May;13(2):82–90. PubMed #31019689.  PainSci #52275. 

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

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

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

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