(Written in a hurry, but hopefully better than nothing.)

Here are three alternative models of what might be happening in people diagnosed with chronic back pain, and repetitive strain injury (RSI), and carpal tunnel syndrome, and maybe other things too:

Three models for certain chronic pain conditions. Left: The model espoused by most people in western medicine. Center: The model espoused by John SarnoHoward SchubinerAlan GordonNicole Sachs, etc. (as I understand it). Right: The model that I personally like and will be discussing in this post.

My guess is that the “mind-body vicious cycle” model (on the right) is the correct story for most people with chronic hand / wrist or back pain (and maybe certain other conditions). Certainly not all people. It’s a big world; different people have different problems. For example, I bet this guy is feeling back pain right now for reasons best explained by the “orthodox” model:

(Granted, this guy wouldn’t technically fall under the definition of chronic back pain. But you get what I’m saying.)

This post will say a bit about the “mind-body vicious cycle” model, why I think it’s a frequent culprit, and how that impacts treatment.

Warning 1: I have no medical expertise, I’m just a rando on the internet writing a blog post. Please don’t trust me when it comes to important medical decisions. :-P

Warning 2: I have a horse in this race, as you’ll see in a second.

1. Reasons to question the orthodox model

1.1 Anecdotes of practically-overnight-permanent-miracle-cures

I’ll start with my own story. Hi! For about a year from 2006-7, I had bad and progressively worse RSI, eventually hampering my ability to use a keyboard, then also mouse, then also pen, and after a while I even got various other weird painful conditions that don’t even make sense. It was a miserable experience and I hate talking or thinking about it, but luckily I wrote up these notes shortly afterwards, so check that out if you want more details, and now let us never speak of it again.

Anyway, after trying everything else, I read the book Healing Back Pain by John Sarno (weirdly—recall that my pain was not in my back!), and within a few days I was totally better in every way forever. (More on that book later.)

(I’m writing this on a cramped laptop keyboard, with terrible posture in every way, just like I’ve been doing pretty much all day every day for years. And I feel perfectly lovely, thank you very much.)

I had read Healing Back Pain on the suggestion of my good friend Andy. He had had a very similar miracle-cure experience. I’ve heard from four people (two friends, two friends-of-friends) that they read my webpage and also had very similar miracle-cure experiences. (Quoth one: “it’s been nothing short of pure magic”.) (Update—make that six—see here and here in the comments section of this very post!) The amazon reviews have page after page of miracle-cure stories like this, and you can find many more at “Rachel’s RSI homage to Dr. John Sarno”, or ThankYouDrSarno.org (exactly what it sounds like), or just by google searching. Celebrities who gushingly praise John Sarno include Howard Stern (who dedicated his first book to his wife, his parents, and John Sarno), Larry David (“the closest I ever had to a religious experience”), and John Stossel (the 20/20 anchor; here’s his effusive segment on Sarno). And you’ll presumably find even more miracle-cure stories if you expand your search beyond John Sarno, to like-minded people like Howard Schubiner, Alan Gordon, Nicole Sachs, etc.

Needless to say, practically-overnight-permanent-miracle-cures are incompatible with the orthodox model. If I have a broken leg, no way am I going to just read a book and then bam, two days later I’m back at the gym jumping rope.

I guess an orthodox-model-advocate could say it’s the placebo effect, where people learn to ignore their pain. But, umm, this is a case where there’s literally no difference between “placebo effect” and “cure”. Call it what you will!

Alternatively, the orthodox model advocate could say that the orthodox model is right for some people but not for others, and that those anecdotes above are coming from the “others”. As mentioned at the top, I have little doubt that this is true to some extent.

Given that, the decision-relevant question for a reader would be: is the orthodox model right for me in particular? Well, check out Sarno’s book (or other resources at the bottom) for more specific diagnostic criteria, assuming you believe these people.

But another helpful datapoint is the base rate. Is the orthodox model right for almost everyone with chronic back or wrist pain, apart from a few weird exceptions like yours truly? Or is it right for most people? Or few people? Or vanishingly few people? This is a question which is obviously hard to answer with anecdotes alone. So let’s switch to other lines of evidence. I think these will be suggestive of the orthodox model being in fact at most a minority of cases.

1.2 Studies showing that “orthodox”-incompatible treatments work quite well for most people

I heard of these two studies from a recent Washington Post article. Note that this article was written (as usual!) by a guy with a horse in this race—his “lifetime of back, neck, stomach, elbow and sciatic pain, along with periodic headaches” were successfully treated by John Sarno.

First study:

“Effect of Pain Reprocessing Therapy vs Placebo and Usual Care for Patients With Chronic Back Pain: A Randomized Clinical Trial” is a newly-published study by a group of famous (and super-biased) people in the Sarno-sphere. Terminology: “Pain Reprocessing Therapy” is I guess some kind of therapy based on John Sarno’s “sneaky subconscious” model (see top diagram, and more on it below). I guess the therapist encourages the patient to believe that their pain is not serious tissue damage, but rather an expression of their anxieties or something.

Results: “Of 151 total participants, 33 of 50 participants (66%) randomized to [the Pain Reprocessing Therapy group] were pain-free or nearly pain-free at posttreatment (reporting a pain intensity score of 0 or 1 of 10), compared with 10 of 51 participants (20%) randomized to placebo and 5 of 50 participants (10%) randomized to usual care.”

Second study:

“Psychophysiologic symptom relief therapy for chronic back pain: a pilot randomized controlled trial” is another newly-published study by mostly authors at Beth Israel Hospital in Boston. In this case, the authors don’t have a glaring conflict of interest, which is nice. Yet the results are about the same:

Results: “At 26 weeks, 63.6% of the [psychophysiologic symptom relief therapy] arm reported being pain free (0/10 pain) compared with 25.0% and 16.7% in [mindfulness-based stress reduction] and usual care arms, respectively.” (Sample sizes of the three groups were 11,12,12, respectively.)

Again, pretty impressive!

As far as I can tell, these are not two cherry-picked examples contradicting a vast ocean of contrary literature. But please let me know if there’s other relevant evidence (for or against) that I should link here.

1.3 Lots of “orthodox” theories seem wrong

A general pattern seems to be:

  • Objective measurements of the presumed root cause of the pain (according to the orthodox theory) reveals that it is actually only weakly (if at all) correlated with the pain; and/or
  • Interventions that remove the presumed root cause of the pain (according to the orthodox theory) are weakly (if at all) more effective than an appropriately-matched placebo (e.g. sham surgery), which is to say, not very effective.

As far as I can tell, this pattern more-or-less applies to the theory that degenerated (or herniated) discs cause back pain, the theory that pressure on the median nerve causes wrist pain (“carpal tunnel syndrome”), the theory that finger pain comes from damage associated with repeated strain (hence the name “repetitive strain injury”), and so on. For example, lots of people in the general population (half?) have degenerated discs and no symptoms at all. Others have back pain, get a scan, find a degenerated disc, schedule surgery, read Healing Back Pain, cancel the surgery, and next month they’re running around as good as new, with that degenerated disc still as degenerated as ever.

Serious physiological damage should be easy to directly measure, I would think. And researchers have been trying to measure it so hard, for so long, that I think the absence of (better) evidence seems to me pretty damning evidence of absence.

(To be sure, everything I mention here has a competing orthodox-model explanation. Maybe surgery often doesn’t work because most surgeons are lousy, or confused about what they’re supposed to be doing, or more generally working off the wrong orthodox-model explanation. Maybe the serious physiological damage in question is in fact extremely hard to measure for whatever reason. Etc. I haven’t dug deeply enough to take a firm stand here.)

2. The “mind-body vicious cycle” model

2.1 What’s the “mind-body vicious cycle” model?

I mostly made up the “mind-body vicious cycle” model, although I imagine that I’m reinventing a wheel. (If so, please share links!) (Sort-of-example.)

As in the diagram at the top, my favored story would be:

  • (1) you think that part of your body is injured, and/or you feel stressed out about the pain, therefore
  • (2) your brain sends (involuntary, viscero-)motor commands that constrict blood flow to that part of your body,[1] therefore
  • (3) using that part of your body is painful, therefore
  • (1) you think that part of your body is injured, and/or you feel stressed out about the pain.

Let’s walk through each step:

The (1) → (2) step might be the well-known (IIUC) tendency for stress to cause vasoconstriction.[2] Alternatively, maybe this step exists as part of an evolved response to mitigate blood loss. We do, after all, know that there’s global blood pressure reduction in response to seeing or imagining bleeding and other injuries (cf. “vasovagal syncope”), presumably to reduce blood loss. Local reduction in blood flow to an injured area seems if anything even more of a good idea, from the perspective of evolutionary design, I figure.

(Of course, you’re not actually bleeding!! But who says that involuntary physiological reactions need to be objectively appropriate to the situation?? By the same token, an elevated heart rate and sweaty palms and dilated pupils aren’t exactly helpful ways to get a high score on your history exam. But your body does it anyway. Or a more direct example is: people get lightheaded when they see someone else bleeding. The point is: these things can misfire.)

The (2) → (3) step seems intuitive enough—for example, blood flow provides oxygen and energy and raw materials to muscles and nerves, and removes waste products. Insufficient oxygen causes muscle soreness, spasms, weird nerve firing, and (presumably) various other effects—or at least, so says John Sarno (see Healing Back Pain chapter 3).

The (3) → (1) step seems like a perfectly sensible psychological response, especially for people who strongly believe in the “orthodox” model.

So, that’s my “mind-body vicious cycle” model.

2.2 How does the “mind-body vicious cycle” model differ from John Sarno’s “sneaky subconscious” model?

John Sarno’s model,[3] as described in Healing Back Pain, is the center column in the image at the top of this post. It shares steps (2) and (3) from the bulleted list above—in particular, the theory that reduced blood flow and oxygen deprivation are the proximal cause of pain—but the ultimate cause is said to be a psychological defense mechanism where your subconscious is trying to cause pain as a sneaky scheme to distract you from stressors like childhood trauma or whatever.

I mostly don’t like John Sarno’s model because I just don’t believe that humans have a “sneaky subconscious” that would do that kind of thing.

The “sneaky subconscious” model also doesn’t jive with my personal experience, although I guess that’s not going to convince anyone else.

3. Positive evidence for the “mind-body vicious cycle” model

3.1 Apparent involvement of medial prefrontal cortex in chronic (but not acute) pain

(This one is really evidence for either “mind-body vicious cycle” or “sneaky subconscious”.)

There’s an article Shape shifting pain: chronification of back pain shifts brain representation from nociceptive to emotional circuits (Hashmi et al., 2013). Here’s the juicy bit:

The mean activation map in early [acute or sub-acute back pain] showed activity extending from the anterior to mid insula bilaterally with contiguous activations in the thalamus, striatum, and lateral aspects of the orbitofrontal and inferior cortex, as well as the dorsal parts of the anterior cingulate cortex. In contrast, [chronic back pain] patients’ mean brain activity was localized bilaterally in the perigenual anterior cingulate cortex (Brodmann area 32) extending into the medial prefrontal cortex (Brodmann area 10) and parts of the amygdala.

I think “emotional circuits” in the title is a confused way to talk about medial prefrontal cortex (mPFC) and anterior cingulate cortex. Instead I offer the following model (based on How Do You Feel by Bud Craig):

My preferred oversimplified model of how to think about medial prefrontal cortex (mPFC) (which includes anterior cingulate cortex) and insular cortex. The brainstem parts of this diagram aren’t relevant for this post but I threw them in anyway—acronyms PAG & PB are “periaqueductal gray” and “parabrachial nucleus”.

I’m never quite sure how much to trust fMRI studies, but this result seems remarkably well-aligned with what I would have expected:

  • The acute back pain group is following the “orthodox model”—the main event in their brain is a pain signal going up from their damaged body to their insula;
  • The chronic back pain group is following the “mind-body vicious cycle model”—the main event in their brain is their medial prefrontal cortex sending (involuntary, viscero-)motor commands for vasoconstriction (and maybe other things too) down to their back.

(It would have been a better match to my expectations if both insula and mPFC were active in the chronic group. Not sure what’s up with that. Maybe the insula was active in both groups, but less active in the chronic group? Not sure—the paper is confusing.)

3.2 Apparent involvement of vasoconstriction

(This one is likewise evidence for either “mind-body vicious cycle” or “sneaky subconscious”.)

There’s a paper “A vascular basis for repetitive strain injury” by Pritchard et al. 1999 which claims that “in diffuse forearm pain the radial artery is relatively constricted compared to the controls and fails to vasodilate with exercise”, based on ultrasound imaging. If I understand correctly, that paper’s authors suggest an “orthodox” model where the proximal cause is structural (obstruction of the arteries prevents them from expanding), whereas I want to explain the same observation via a “mind-body vicious cycle” model where the proximal cause is in the nature of the visceromotor commands being sent from the brain to the (involuntary) vasoconstriction muscles.

(That’s just one paper, but different researchers found compatible results by a different method here. I haven’t done a deeper dive than that.)

Another possibly-relevant datapoint on this topic that I’ve seen is—and I hardly need to mention that this is not a particularly reliable source—an anecdote from this weird book with a creepy alien on its cover that my wife and I read at a hospital birthing class before our first kid:

When the mother approaches labor with unresolved fear and stress, her body is already on the defensive…. This causes the arteries going to the uterus to tense and constrict, restricting the flow of blood and oxygen. Labor and birthing nurses and midwives have told me of seeing uteruses of frightened birthing women that are white from lack of blood, just as a person who is experiencing extreme fright often has the blood drain from his face.

With limited oxygen and blood, vital to the functioning of the muscles in the uterus, the lower circular fibers at the neck of the uterus tighten and constrict, instead of relaxing and opening as they should… When these two sets of muscles work against each other, it causes considerable pain for the laboring mother… —p53 here

Again, this is not a great source, but I find it intriguing, especially if the (sketchy, undocumented) claim that terrified women have white, starved-of-blood uteruses is both true and has the implied cause-effect relationship.

What about back pain? Healing Back Pain has some references:

There is also laboratory evidence for this concept. In 1973 two German research workers, H. G. Fassbender and K. Wegner, reported finding microscopic changes in the nuclei of biopsied muscles from back pain patients suggesting oxygen deprivation in “Morphologie und Pathogenese des Weichteilrheumatismus,” Z. Rheumaforsch (Vol. 32, p. 355).

For additional evidence on the critical role of oxygen in [chronic back pain] we are indebted to a group of research workers who have demonstrated in their laboratories in recent years that muscle oxygenation is low in patients suffering from a disorder known as primary fibromyalgia. Typical of these reports is one published in the Scandinavian Journal of Rheumatology in 1986 (Vol. 15, p. 165) by N. Lund, A. Bengtsson and P. Thorborg titled “Muscle Tissue Oxygen Pressure in Primary Fibromyalgia.” Using an elegant new laboratory tool, they were able to measure muscle oxygen content with great accuracy and found that it was low in the painful muscles of patients with fibromyalgia.

(I think the two papers he cited, like everything else in this section, should be treated as merely suggestive, as opposed to strong evidence. I haven’t tried to dive into the literature myself.)

3.3 “Vicious cycle” seems like a pretty good fit to the dynamics

Leaving aside the exact nature of the vicious cycle, the general idea that there’s a vicious cycle seems to me like the right dynamic. A vicious cycle provides a natural explanation for why the pain tends to have better and worse phases over days and weeks and months—whereas your mood can change in minutes, and your thoughts in seconds.

Also, a vicious cycle suggests a susceptibility / trigger split that rings true to me:

  • Susceptibility to the vicious cycle means that, if there’s pain, it’s liable to become self-sustaining. People might be more or less susceptible to the vicious cycle for various reasons, including general stress and anxiety etc., or simply from very strong belief in the orthodox model! (…with extra bonus points if they have friends who were forced to quit their jobs and upend their lives due to chronic pain!)
  • Trigger would be something that starts the vicious cycle—I presume typically a conventional / “orthodox” cause of pain or discomfort (acute injury, muscle soreness, spasm, etc.) That original cause of pain would heal itself on the usual schedule, but in the meantime the vicious cycle has spun itself up and persists.

4. If “mind-body vicious cycle” is the right model [for a particular person], then what?

For me, it was just reading Healing Back Pain, and all the testimonials in Section 1.1, then deciding to live normally starting the next morning (keeping in mind that my muscles would be sore from exercise after a long period of disuse), and I felt better over the course of the next couple days.

Ironically, I didn’t even like Healing Back Pain that much—most of it struck me as a bunch of baloney, for the reason mentioned above (i.e., I don’t believe that humans have a “sneaky subconscious” of the type that Sarno was proposing). But that’s not too weird. After all, it’s very common in medicine for people to come up with an effective treatment despite a wrong theory (or no theory) about why that treatment works. Maybe the main thing I got out of the book was self-confidence that I didn’t have very-slow-healing semi-permanent tissue injuries, and that’s all I needed.

(It was only many years later that I invented (or maybe reinvented) the “mind-body vicious cycle” model.)

Oh, I also liked some of the practical advice in the book. For example, Sarno’s book suggested “talking to your brain”. I recall finding that tip very helpful. If memory serves, I had some very choice words for my brain, which need not be repeated in this family-friendly blog post.

In hindsight, the other thing I should have done before starting is to go through the “positive reframing” technique from Feeling Great (see my book review). If there were a magic button that eliminated all the caution, stress, anxiety, tension, etc., that I felt before and during typing, would I have any motivation not to push that button? I have to admit that I did have such counter-motivations—in particular, (1) Even after all the reading and thinking, maybe I still had slight lingering concern that the “orthodox” model was correct after all, and the caution and tension were protecting me, and I was going to make things even worse, (2) I had certain unsympathetic friends who I knew would declare “It was all in your head after all, I told you so, nyah nyah nyah pfffft”, if I were to have the miracle-cure experience that I was hoping for, and that was an aversive thought.[4] In my case, those counter-motivations were weak enough that they didn’t cause any problem—the treatment immediately worked for me anyway. But I imagine that counter-motivations are a bigger roadblock for some other people, just as counter-motivations are often a roadblock for people suffering depression, anxiety, phobias, OCD, and all sorts of other unpleasant conditions (again, see Feeling Great). That may account for why Sarno-style treatments can (apparently) sometimes not work immediately, but work after some therapy and talking about childhood trauma or whatever.

Other possibly-relevant resources that I haven’t tried and can’t vouch for:

And most importantly, reading the testimonials in Section 1.1.

(Previous discussion on LessWrong: Alex Turner’s anecdotermoehn’s anecdote & discussionrelated question. See also Scott Alexander’s “Book Review: Unlearn Your Pain”.)

(Thanks rmoehn for critical comments on a draft.)

  1. ^

    I’ll be arguing for a particular model involving blood flow and oxygen deprivation, but I can imagine various other possibilities in the same “genre”, and these might not even be mutually exclusive. For example, maybe stress causes inappropriate muscle tension which makes the muscles painful to use which causes stress.

  2. ^

    See Why Zebras Don’t Get Ulcers for more discussion of the stress-body connection.

  3. ^

    Warning: I’ve only read Healing Back Pain by John Sarno. I assume that his fellow-travelers like Howard Schubiner, Alan Gordon, Nicole Sachs, etc. all espouse the same theory, but I didn’t check; it’s possible that there are differences among them.

  4. ^

    As it turns out, I needn’t have worried, everyone was very kind and sympathetic. But I didn’t know that at the time.

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24 comments, sorted by Click to highlight new comments since: Today at 7:00 PM

I find I have to caveat somewhat when I recommend Sarno to people because he makes the same mistakes as the early somatic people he talks extensively about makes in that he denigrates other methods or the idea that injuries could be structural way too harshly instead of a more measured approach that things can be a combination of factors including the vasoconstriciton and that it is incredibly helpful to separate out these factors for separate treatment.

There is another model, wherein the problem is trigger points. Trigger points crop up when a muscle is under strain, and then they tend to stay that way. Trigger points, once created, constrict blood flow or impinge on nerves, creating all sorts of problems. (My dentist referred me to an oral surgeon twice for things that later turned out to be trigger points: my teeth had gotten sensitive after dental work, but it turned out that I developed trigger points from having my mouth open for hours during the procedure. Now I know where to massage my neck and jaw to prevent tooth sensitivity from arising in certain areas of my mouth after dental work.)

I used to have wrist pain a lot, and tried a ridiculous number of things to deal with it until I discovered the trigger point concept. Over time I've learned to identify which trigger points produce what symptoms for me, and what postures or behaviors set off the trigger points.

Before that, I considered Sarno but didn't get much benefit from it. I have nonetheless noticed that you don't need a "sneaky" subconscious for Sarno to be meaningful, however: if you go around constantly suppressing rage, you can easily put some muscles under chronic strain. This isn't really "subconscious" except in the same way that we "subconsciously" drive a car or perform any other habit. Most people tense their muscles when trying to "suppress an emotion", or rather, trying to inhibit their expression of that emotion.

And before Sarno, I did Egoscue work -- a bunch of exercises to improve posture, which did help with wrist pain, but they required an hour or more of exercise per day during which I couldn't do anything else and the improvement was very gradual. I think the exercises were good in general and I still do some of the ones that produce fast pain relief in certain areas when a trigger point flares up and I'm still getting it to un-knot.

Anyway, my prior now for "mysterious chronic pain" is "check for trigger points creating referred pain". Most often this consists of following the nearest muscles, nerves, or blood vessels in the direction of the spine or brain, checking for tenderness. A sharply sensitive spot is likely a trigger point, so I press deeply on it for a minute (as in 60 seconds) and see if the original pain is made worse or better. If nothing happens to it, it's probably not the trigger point. (Pressing on a trigger point can make the pain temporarily worse, but the pain will reduce again when the trigger point releases or un-knots.)

This simple search algorithm is far from perfect, especially once you get up into tricky areas like shoulders, underarms, neck and head. Some trigger points are in muscles underneath other muscles, or otherwise difficult to get to, and others are in counterintuitive locations for what they do. (Like the spots on my chest that I need to massage if the tip of my index finger feels numb or tingling.) It's generally a good idea to consult a proper reference chart of trigger points, but since "look for tenderness along the obvious-to-me paths" works well for a lot of limb stuff, and I've mostly looked up the weird ones most relevant to me, it saves me some time.

I would modify the theory slightly by noting that the brain may become hypersensitive to sensations arising from the area that was originally damaged, even after it has healed. Sensations that are otherwise normal can then trigger pain. I went to the website about pain reprocessing therapy and stumbled upon an interview with Alan Gordon where he talked about this.  I suspect that high level beliefs about tissue damage etc play a role here also in causing the brain to become hyper focused on sensations coming from a particular region and to interpret them as painful. 

Something else that comes to mind here is the rubber hand illusion. Watch this video - and look at the flinches! Interesting, eh? 

edit: (ok, the rubber hand illusion isn't clearly related, but it's interesting!) 

So what is the treatment?

I thought I addressed that in Section 4. Did  you miss that? Or are you asking me to spell out all the details? If the latter, sorry, I don’t want to spend my time doing that, and might not do a good job anyway.

Probably it's just me, but even after rereading Section 4 I have absolutely zero clue what Sarno's treatment consists of. I wasn't looking for all the details, just one sentence would have been nice? 

First paragraph of section 4. The extremely-minimalist description would be: “Stop believing in the orthodox model, stop worrying, feel and act as if you’re healthy, and then the pain goes away”. (The idea is to break the vicious cycle at the “step (1)” part, in terms of the Section 2.1 bulleted list.) Maybe you were expecting something more than that?

Of course, that’s much easier said than done. So reading the books / testimonials / other resources is good for both gaining the needed confidence, and learning various helpful mental tips and tricks. I guess John Sarno gives his in-person patients some kind of therapy / counseling / something, but I don’t remember exactly what that entails, and I personally didn’t need anything like that myself.

The extremely-minimalist description would be: “Stop believing in the orthodox model, stop worrying, feel and act as if you’re healthy, and then the pain goes away”. 

IDK if this will be important to you, but I'd like to thank you for this comment, as it relieved my back pain after 8 years! Thank you @p.b. for asking for clarification and not giving up after first response. Thank you @Steven Byrens for writing the article and taking time to respond.

8 fucking years..

I've read this article and comments a month ago. Immediately after reading it the pain was gone. (I never had mystical experiences, like enlightenment, so the closest thing I can compare it to personally, was the "perspectival shift" I've felt ten years ago when "the map is not the territory" finally clicked)

I know - it could've been "just a placebo effect" - but as the author argues, who cares, and that's kinda the main point of the claim. Still, I was afraid of giving myself a false hope - there were several few days long remissions of pain scattered along these 8 years, but the pain always returned - this is why I gave myself and this method a month before writing this comment. So far it works!

I know - "Post hoc ergo propter hoc" is not the best heuristic - there could be other explanations of my pain relief. For example a week or two before reading this article I've started following this exercise routine daily. However, I've paused the routine for three days before reading your article, and the pain relief happened exactly when I've finished reading your comment, so IMO timing and rarity (8 years...) of the event really suggests this comment is what helped. I still do the exercise routine, and it surely contributes and helps, too. Yet, I do the routine just once in the morning, yet I consciously feel how whenever throughout the day the pain starts to raise its head again, I can do a mental move inspired by this article to restore calm and dissolve the pain.

Also this is definitely how it felt from the inside! In the hope that it will help somebody else alleviate their pain here are some specific patterns of thoughts induced by this article I found helpful:

  • "oh, so my pain-center is simply confused about the signals, it is screaming like a child who can't express well what's wrong, and I was overreacting. I should show it love, not anger, I should calm it down, I must be the adult in the room and figure out what's the real problem here."
  • "I should ignore the pain by gently putting the pain to the side (like you do to the thoughts during meditation) as opposed to fighting through it. Like hitting snooze, vs clenching my jaw and fist to overcome it."
  • "yeah, I've heard you pain-center, but I think you are mistaken about the magnitude and source of the problem, and I am actively working on the solution to the real problem, so please do not distract me while I am helping you"
  • "the pain-center is presenting me a whole crayon-drawn image of a tiger, but it was just connecting-the-dots creatively, and there really was no tiger, just the dots". I think this one is most helpful metaphor for me. I can feel how I dissolve a full certainty of "the pain of the whole upper back" into individual, small, shaky dots of unsure signals from small patches of the back.
  • "looks like it was just one small place around this shoulder blade which started the alarm, maybe I should just change the position of right arm, oh, yes, this brought relief, good"
  • "ok, so this part near neck is so tense it started complaining, and this was probably because I was trying too hard to finish answering this email before visiting the restroom - let's just give myself a pause and treat the body more gently".
  • "ok, I need to be more precise: which patch of my back is in pain right now? If I can't tell, then perhaps it's something in the environment that is causing stress, or some thought, or some anticipation, or maybe some physiological need? Let's look around and find out what this alarm is about"
  • The Bohr's horseshoe: "I was told that it works even if you don't believe in it"
  • I just imagine a volume knob on the pain and just turn it down

I am really excited about all this positive change in my mind, because as one can imagine (and if you can't, recall main character of House M.D.) a constant pain corrupts other parts of your mind and life. It's like a prior to interpret every sentence of family-members and every event in life. It's a crony belief, a self-sustaining "bitch eating cracker syndrome". It took 8 years to build this thought-cancer, and it will probably take some time to disband it, but I see the progress already. 

Also, I am "counter-factually frightened" by how close I was to completely missing this solution to my problem. I was actively seeking, you see, fruitlessly, though, for years! I had so much luck: to start reading LW long ago; to subscribe Scott Alexander's blog (I even read his original review of "unlearn your pain" from 2016 yet it sounded negative and (I) concentrated too much on discrediting the underlying model of action, so perhaps I could fix my pain 6 years earlier); to develop a habit of reading LW and searching for interesting things and reading comments, not just the article.. Thank you again for this article and this comment thread. When I imagine how sad would be the future if on that afternoon I didn't read it I want to cry...

oh wow, this is super helpful to me! thank you for bumping the post with useful insight!

Thanks for sharing, that made my day!!!   :)

That's really cool, thanks for sharing!

The most helpful thing my physiotherapist did when he treated me for chronic back trouble: making the observation that there was a considerable amount of avoidance behavior on my part. Stopping that and becoming more active has greatly reduced my back problems.

Yeah, I thought that was just what you did. I expected Sarno to have some kind of program. But ok, if that's it, that's it.

A small bit of anecdata in favor of the vasoconstriction mechanism: I'm about two weeks into a flare up of upper back soreness/tightness/yeck. It's been a bit chronic/mild for... maybe six months, but I did some stuff that flared it up to... 1.3/10ish two weeks ago. Uncomfortable, and concerning, but not crazy. What was worrying was that it didn't seem to be resolving. Sitting at the computer definitely made it worse. I tried some alternations to my seating (currently not very ergonomic for logistic reasons that are taking time to fix). Adding lower back support pillows didn't help. I tried a bunch of self massage; possibly made it slightly worse. I tried a bunch of gentle mobilization and some moderate weight resistance training. Possibly made it slightly worse. I tried walking a lot. That... tended to make it slightly better, but the effect went away quickly if I spent time sitting. I read this post and tried shoving a hotwater bottle down the back of my t-shirts while working at the computer. That produced a large improvement gradient. I guess you could tell the story that the heat is counter the vasoconstriction. The effect doesn't seem to be present if the water bottle is room temperature, but I also haven't tried that much.

It's not the most practical solution -- I just got a kneeing chair, and have a proper office chair en-route too. But it's def been helpful.

Healing Back Pain makes a claim along those lines (p62):

One body of evidence that the physiologic alteration in TMS is oxygen deprivation is clinical. It has long been recognized that heat, introduced into muscle by diathermy or ultrasound machines, will relieve back pain temporarily. So will deep massage and active exercise of the muscles involved. All three of these physical measures are known to increase blood flow through muscle. Increased blood flow means more oxygen, and if that relieves pain it is logical to assume that oxygen deprivation was responsible for the pain.

Yeah, as a 1.5 week follow up, the heat treatement has continued to has continued to be effective, with the sense of tightness continuing to resolve. But it's also required a fairly high dose: probably several hours a day sitting with the waterbottle shoved into my t-shirt. I have a more ergonomic chair arriving tomorrow, G-d and B-zzos willing.

4 month follow up: a lot of heat was very helpful, but underpowered to fully deal with this problem, and also inconvenient to constantly have a hotwater bottle in the back of my sweater like a hunchback of Notre Dame. Gently ramped up, progressive upper back strengthening has been very helpful for getting to a much more sustainably comfortable point. There's still some lingering issues in the spot between the shoulder blades and occasionally I do still treat with heat, but it's much much better now.

I think this hypothesis for some kinds of chronic pain makes sense and is helpful to me. Thanks for posting. The only thing I would comment on is in regard to the physiological mechanism at work. For me, the vicious cycle enabler of my own chronic pain (neck - ascribed to incipient arthritis, wheneverI ask a professional) is, I’m pretty sure, not blood flow restriction but muscle spasming. I wonder if others might say the same? I do find it is frequently self-fulfilling. If I think I’m going to get a seriously stiff neck in the night, then I will get a seriously stiff neck by morning plus accompanying serious headache.  I too have no medical training so disclaimers as to what is really going on.

Hmm. Speculating on some possibilities:

  1. Vasoconstriction commands from the brain → Nerve doesn’t get enough blood → abnormal nerve firing → muscle spasm
  2. Vasoconstriction commands from the brain → Muscle doesn’t get enough blood → muscle has insufficient oxygen, buildup of waste products, ion imbalance, etc. → muscle spasm
  3. Skeletal muscle commands from the brain → “chronic, excessive muscle tone” → muscle spasm

(I’m speculating that 1 and/or 2 might be real things, on the basis that you can get muscle spasms after a really intense workout.)

I know very little about the physiology of muscle spasms. But it’s fun to speculate! And thanks for your comment :)

I've dealt with chronic pain for the better part of a decade and I've come to almost the same conclusion independantly.

I wanted to say thank you for this post - I'm 26 years old, and up until last year I'd been afflicted with back pain that would onset after standing still for an extended period of time. I think it started after doing hang-cleans with bad form when I was in high school. Over the years, the amount of time it took for the pain to appear got shorter and shorter, and the pain grew more and more intense, to the point where I would be uncomfortable and unable to enjoy myself after standing for more than ~45 minutes.

Knowing that I would eventually be in pain if I stood for too long would make me seek out opportunities to sit, trying to "conserve" my comfortable standing time. I would squat, lean against things, shift my weight oddly - anything to keep from standing still. If I found myself with no other option but to stand, it would be hard for me not to think about the fact that I would eventually begin hurting.

This sucked, especially since one of my favorite activities is going to concerts, where I may have been forced to stand for a few hours by the time the headliner even comes on. I remember going to lots of shows where I just wasn't able to appreciate the music because my thoughts were with my back. I would dance, not for pleasure, but as a way of avoiding standing still

I was really interested reading your post, and it was swirling around in my mind while I was at a music festival about a week after I read this post. On the second night of the festival, I was tripping on a half tab of acid. My back had begun to hurt to the point that I needed to sit down, but then I thought of this post, specifically this paragraph:

For me, it was just reading Healing Back Pain, and all the testimonials in Section 1.1, then deciding to live normally starting the next morning (keeping in mind that my muscles would be sore from exercise after a long period of disuse), and I felt better over the course of the next couple days

In that moment, I did what you did. I decided the pain was just pain, and I didn't have to recoil away from it. I stayed on my feet and realized that the pain wasn't as unbearable as I had built it up in my head to be. Being on a psychedelic, I even imagined the pain as a ball of light that traveled up my back and out my arm, at which point I stopped feeling it.

The next two days I tested whether this was a permanent effect. I deliberately stood still for much longer than I would have otherwise. I noticed some soreness around where the pain used to appear since I'd been avoiding using those muscles, but otherwise the difference was night and day.

That Sunday at the festival was one of the happiest days of my life. I threw my hands in the air, laughed loudly, and jumped around, soaking in the moment fully sober. It felt like my youth had been returned to me. I stood around for no reason at all wearing a massive smile while my friends took breaks to sit. I danced purely for pleasure for the first time in many years. I told my friend it was as though someone had just deposited a million dollars into my bank account. I was fully convinced I would live with a debilitating pain for the rest of my life before this experience, and now I can stand for hours comfortably. The soreness has even gone away as I stood more often and strengthened my lower back muscles.

I have tears in my eyes as I write this. I'm not sure if I ever would have come across Healing Back Pain on my own or if I would have found it convincing, but your post got through to me and it has made a massive positive impact on my life. Thank you.

Thank you for sharing, I'm so happy to have helped!!!!

What's your subjective probability that this model is correct, and for what proportion of people suffering from chronic pain? I must admit that it sounds rather sketchy to me. Alternative medicine usually sends my crackpot alarms blaring. But I have two family members with chronic pain, so this is interesting to me.

The studies in Section 1.2 suggest a first-pass guess that 65% of the population [that those studies were drawing from] is "non-orthodox".

…But then you'd need corrections, like if there's an "orthodox" subset of the population, then some of them might heal by coincidence despite being in the non-orthodox treatment group, and in the other direction (maybe more importantly) there could be non-orthodox people who didn't respond to the non-orthodox treatment. Actually, the latter would hardly be surprising, particularly given that I think the non-orthodox treatment providers are very confused about what they're doing and why it works. I think "95% of the population are non-orthodox, or even more" should remain on the table as a possibility. Much lower numbers are also on the table. I don't immediately know how to narrow it down.

As for subjective confidence, umm, I'm 95% confident that if I spent more time and did more research I would want to make at least minor edits to the model I'm proposing, and 25% that I would want to make major edits. But I don't really expect that my probabilities are calibrated on this anyway, so maybe those numbers are a bit meaningless.

Hope that helps.

For what it’s worth, I share your general skepticism towards "alternative medicine". As mentioned in the post, I thought the Healing Back Pain book had a bunch of baloney in it, even at the very moment that I was benefiting so much from it. I continue to have no interest in alternative medicine apart from this one topic.

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