• 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

There are many causes of pain that do not entirely or directly cause pain: not a tidy B-follows-A cause and effect relationship. Instead, some of the most important causes of pain are the general conditions in which it 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 impossibke 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 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 sometimes very hard to find, it’s that they aren’t alone. In cases of chronic widespread pain (“fibromyalgia”), these non-specific vulnerabilities might actually 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 32 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 a tough time digging her way out of that mess. And yet it could be her only real hope of a cure from a serious chronic pain that has been driving her nuts.

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: 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.

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. 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:

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 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 not-terrible 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 never super-sized, you drink more water than soft drinks, there’s not much deep fried, and very little of the food is fast food. It’s not about superfoods 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 your neck pain. See Chronic, Subtle, Systemic Inflammation: One possible sneaky cause of puzzling chronic pain.


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.

Make more friends

Social isolation, AKA “loneliness” for those who are unhappy with being isolated,4 is a major general health suppressor in the same league as anxiety and chronic stress, sedentariness, smoking, sleep deprivation, and metabolic syndrome.5 It almost certainly involves increased vulnerability to chronic pain as part of the deal, and some evidence definitely suggests this.6 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. In other words, you have more to worry about when you’re lonely.

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 vulnerability-reducing stuff would be a complete personal makeover. You could literally spend the rest of your life working on it, just generally 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.

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. BACK TO TEXT
  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. “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. BACK TO TEXT
  5. 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.BACK TO TEXT
  6. 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).