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Reference topic 21: The Pain You Were Not Supposed to Keep

Chronic pain and back pain: why pain persists

ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.62 sources7 graded recommendationsTopic hub: Movement

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In the early 2000s, the anthropologist Michael Gurven and a Tsimane research assistant went door to door in 16 villages in lowland Bolivia. In the Tsimane language, they asked 388 people aged 10 to 75 whether they hurt in the back (murujru), arm, hand, leg or foot.1

The Tsimane farm, hunt, fish and forage, and carry their rice in bags strapped across the head or shoulders. Their hearts show the lowest levels of coronary artery disease yet recorded (Topic 8).2 If lasting pain were a disease of desks and sofas, the Tsimane should have been spared it.

Mismatch card

The system

Pain, the body's protective alarm, and the opioid and endocannabinoid systems that quiet it.

What it expects

Injury, then a return to use while still sore, among people who help.

What it gets

Rest, scans that find "damage" in pain-free people, fear and, for a time, freely prescribed opioids.

What happens in the gap

A sensitized alarm keeps ringing after tissue heals, and ordinary pain hardens into disability.

The handrail

Keep moving, skip routine scans, retrain the alarm, protect sleep and company (●●○)

Strength of evidence

●●○ Trials firmly support movement and oppose routine imaging and opioids for back pain, but the mismatch account of why pain persists remains a hypothesis.

What this topic covers

  • ·The Alarm You Cannot Live Without
  • ·Hurt, and Working Anyway
  • ·The Epidemic Was Disability
  • ·A Nervous System That Learns
  • ·Unlearning the Alarm
  • ·The Poppy and the Pill
  • ·The Runner's High

The practical version is in the book: Chapter 3, The Body That Walks.

The handrail

Almost everything that works for persistent pain asks you to move sooner than the pain suggests.

Each recommendation carries the strength of the evidence behind it. How the grades work.

  1. When your back first hurts, keep going

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.

    Stay as active as pain allows. Bed rest slowed recovery,9 and most acute back pain settles within weeks, with or without paracetamol (acetaminophen).51 Seek urgent care for back pain after a serious accident, or with weakness, tingling or numbness in both legs, numbness around the genitals or anus, bladder or bowel changes, chest pain, or fever. See a doctor for pain that is worse at night, comes with unexplained weight loss, or lingers beyond a few weeks.52

  2. Skip the routine scan

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.

    Without warning signs, imaging does not improve outcomes, and "abnormal" findings are common in pain-free people of every age.2120

  3. Move as treatment

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.

    Evidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism. for pain·Evidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials. for any particular dose

    Choose exercise you will keep doing. In people recently recovered from back pain, a walking and education program that built up over three months to at least 30 minutes, five times a week, cut relapses (Topic 2).53 Start low and build slowly; in some people with chronic pain, exercise briefly increases pain.54 In chronic fatigue syndrome (also called myalgic encephalomyelitis), the National Institute for Health and Care Excellence advises against graded exercise therapy.55

  4. Retrain the alarm

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.

    Evidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism. for CBT and mindfulness·Evidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials. for pain reprocessing therapy

    Learning how pain works does little for pain on its own.46 Structured treatment does more: eight weekly two-hour group sessions of CBT or mindfulness,27 or pain reprocessing therapy, eight one-hour sessions over four weeks.23 Treating the alarm does not mean the pain is imaginary.

  5. Protect sleep

    ProbableEvidence grade: Probable. Good observational evidence with a plausible mechanism, or small or few trials.

    One sleepless night lowered pain thresholds in 25 healthy adults,56 and in people with both insomnia and chronic pain, CBT for insomnia improves sleep substantially and pain modestly (Topic 41).57

  6. Keep people close

    EmergingEvidence grade: Emerging. Early, small, animal-only, or actively contested.

    Laughing with friends released opioids in the brains of 12 men, and holding a husband's hand damped the brain's threat response in 16 women (Topic 42).3158

  7. Use medicines safely

    StrongEvidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism.

    guideline·Evidence grade: Strong. Multiple randomized controlled trials, or consistent large cohort studies with a well-understood mechanism. for agonist treatment

    The World Health Organization advises against opioids as routine care for chronic primary low back pain.59 Never stop or rapidly cut prescribed opioids on your own: tapering has been linked to overdoses and mental health crises, so reduce slowly on a plan made with your clinician.5060 For opioid dependence, methadone or buprenorphine treatment is associated with less than half the risk of death.61 Keep naloxone, sold over the counter in the US since 2023, if anyone at home uses opioids.62

The skeptic's corner

The case against this topic, from the research itself.

Pain reprocessing therapy rests on one full trial of mostly white, college-educated volunteers with low-to-moderate pain, treated by experts in the method. Two authors have commercial ties to it, and the team calls for trials in more severe pain.2324 Education alone disappoints. Across a dozen trials, its short-term effects on pain and disability were of "low clinical relevance."46 For new back pain at high risk of lingering, it left pain no lower than sham education did.47 Exercise eases pain moderately and function only a little, and no trial can hide from people whether they are exercising.25 Central sensitization is real but often invoked loosely. Woolf himself has called for diagnostic criteria and objective biological markers.17

The Tsimane data are self-reported, questionnaires and norms for admitting pain differ between studies, and the current-pain comparisons were mostly with non-industrial or middle-income countries.1 An older review found the reverse: back pain two to four times more common in Swedish, German and Belgian populations than among farmers in Nigeria, southern China, Indonesia and the Philippines. Its author, though, judged a high proportion of such surveys "methodologically questionable."48 Williams's inactivity hypothesis sits awkwardly with Tsimane who work through pain and still hurt; too much load and too little movement may both matter. The belief experiments are observational, and a smaller Norwegian campaign changed beliefs but not sick leave.49 The runner's high is unsettled too. Blood levels are an indirect window on the brain, and brain scans point to opioids as well.42

Opioids, finally, have a place. They remain among "the most effective drugs known for acute relief of severe pain."41 The prescribing guideline of the US Centers for Disease Control and Prevention does not cover cancer, sickle cell, palliative or end-of-life pain.50 Nothing in this chapter argues against opioids where they are needed.

Terms this topic defines

Related topics

Sources cited above

  1. 1.Stieglitz, J., Buoro, Y., Beheim, B., Trumble, B.C., et al. (2023). "Labour's pain: strenuous subsistence work, mechanical wear-and-tear and musculoskeletal pain in a non-industrialized population." Proceedings of the Royal Society B, 290(1998), 20222497. https://doi.org/10.1098/rspb.2022.2497 (388 participants in 16 villages, interviewed May 2002 to December 2004. Current-pain comparison populations: Iran, Philippines, Australia, Indonesia, Bangladesh, Vietnam; 2.5-8.2 times for men and 1.7-6.5 times for women. Chronic-pain comparisons: Sweden, Scotland, Ireland, Canada, USA, Denmark; Tsimane men's prevalence "either within the range of variation observed in other populations, or higher," women's within the range. Interview details from the full text.) (nearly all the pain was felt while working; loads of plantains and rice are carried in woven saraij bags; fields are cleared with machetes and axes; a man's hunt averages 8.4 hours and 17.9 km; the other sites asked about were the arm, uñya'; the foot, yuj; the hand, un; and the leg, jäñäc)
  2. 2.Kaplan, H., Thompson, R.C., Trumble, B.C., Wann, L.S., et al. (2017). "Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study." The Lancet, 389(10080), 1730-1739. https://doi.org/10.1016/S0140-6736(17)30752-3
  3. 23.Ashar, Y.K., Gordon, A., Schubiner, H., Uipi, C., et al. (2022). "Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: a randomized clinical trial." JAMA Psychiatry, 79(1), 13-23. https://doi.org/10.1001/jamapsychiatry.2021.2669 (sample 86-92% white and 70-78% college graduates across arms; commercial ties disclosed by A. Gordon and H. Schubiner; imaging and limitation details from the full text, PMC8482298) (enrollment from late 2017; all 20 therapy patients with old spine scans had abnormalities, a median of four)
  4. 24.Ashar, Y.K., Low, E.L., Knight, K., Schubiner, H., et al. (2025). "Pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: 5-year follow-up of a randomized clinical trial." JAMA Psychiatry, 82(10), 1049-1051. https://doi.org/10.1001/jamapsychiatry.2025.1844 (113 of 151 participants assessed)
  5. 46.Watson, J.A., Ryan, C.G., Cooper, L., Ellington, D., et al. (2019). "Pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis." Journal of Pain, 20(10), 1140.e1-1140.e22. https://doi.org/10.1016/j.jpain.2019.02.011 (12 trials)
  6. 47.Traeger, A.C., Lee, H., Hübscher, M., Skinner, I.W., et al. (2019). "Effect of intensive patient education vs placebo patient education on outcomes in patients with acute low back pain: a randomized clinical trial." JAMA Neurology, 76(2), 161-169. https://doi.org/10.1001/jamaneurol.2018.3376 (two hours of education; pain measured three months later)
  7. 25.Hayden, J.A., Ellis, J., Ogilvie, R., Malmivaara, A., and van Tulder, M.W. (2021). "Exercise therapy for chronic low back pain." Cochrane Database of Systematic Reviews, 9(9), CD009790. https://doi.org/10.1002/14651858.CD009790.pub2 (pain -15.2 points on 0-100 at earliest follow-up; 79% of trials at risk of performance bias) (a clinically important difference)
  8. 17.Woolf, C.J. (2011). "Central sensitization: implications for the diagnosis and treatment of pain." Pain, 152(3 Suppl), S2-S15. https://doi.org/10.1016/j.pain.2010.09.030
  9. 48.Volinn, E. (1997). "The epidemiology of low back pain in the rest of the world: a review of surveys in low- and middle-income countries." Spine, 22(15), 1747-1754. https://doi.org/10.1097/00007632-199708010-00013
  10. 49.Werner, E.L., Ihlebaek, C., Laerum, E., Wormgoor, M.E., and Indahl, A. (2008). "Low back pain media campaign: no effect on sickness behaviour." Patient Education and Counseling, 71(2), 198-203. https://doi.org/10.1016/j.pec.2007.12.009
  11. 42.Boecker, H., Sprenger, T., Spilker, M.E., Henriksen, G., et al. (2008). "The runner's high: opioidergic mechanisms in the human brain." Cerebral Cortex, 18(11), 2523-2531. https://doi.org/10.1093/cercor/bhn013
  12. 41.Williams, J.T., Ingram, S.L., Henderson, G., Chavkin, C., et al. (2013). "Regulation of mu-opioid receptors: desensitization, phosphorylation, internalization, and tolerance." Pharmacological Reviews, 65(1), 223-254. https://doi.org/10.1124/pr.112.005942
  13. 50.Dowell, D., Ragan, K.R., Jones, C.M., Baldwin, G.T., and Chou, R. (2022). "CDC Clinical Practice Guideline for Prescribing Opioids for Pain: United States, 2022." MMWR Recommendations and Reports, 71(3), 1-95. https://doi.org/10.15585/mmwr.rr7103a1
  14. 9.Malmivaara, A., Häkkinen, U., Aro, T., Heinrichs, M.L., et al. (1995). "The treatment of acute low back pain: bed rest, exercises, or ordinary activity?" New England Journal of Medicine, 332(6), 351-355. https://doi.org/10.1056/NEJM199502093320602
  15. 51.Williams, C.M., Maher, C.G., Latimer, J., McLachlan, A.J., et al. (2014). "Efficacy of paracetamol for acute low-back pain: a double-blind, randomised controlled trial." The Lancet, 384(9954), 1586-1596. https://doi.org/10.1016/S0140-6736(14)60805-9 (median recovery 16-17 days in all arms)
  16. 52.NHS (2026). Back pain. https://www.nhs.uk/conditions/back-pain/
  17. 21.Chou, R., Fu, R., Carrino, J.A., and Deyo, R.A. (2009). "Imaging strategies for low-back pain: systematic review and meta-analysis." The Lancet, 373(9662), 463-472. https://doi.org/10.1016/S0140-6736(09)60172-0
  18. 20.Brinjikji, W., Luetmer, P.H., Comstock, B., Bresnahan, B.W., et al. (2015). "Systematic literature review of imaging features of spinal degeneration in asymptomatic populations." American Journal of Neuroradiology, 36(4), 811-816. https://doi.org/10.3174/ajnr.A4173 (33 studies of 3,110 people; disc degeneration in 37% of 20-year-olds and 96% of 80-year-olds; disc bulges in 30% and 84%)
  19. 53.Pocovi, N.C., Lin, C.C., French, S.D., Graham, P.L., et al. (2024). "Effectiveness and cost-effectiveness of an individualised, progressive walking and education intervention for the prevention of low back pain recurrence in Australia (WalkBack): a randomised controlled trial." The Lancet, 404(10448), 134-144. https://doi.org/10.1016/S0140-6736(24)00755-4 (701 adults; hazard ratio for an activity-limiting recurrence 0.72). Walking dose from Pocovi, N.C., Graham, P.L., Lin, C.C., French, S.D., et al. (2023). "Effectiveness and cost-effectiveness of a progressive, individualised walking and education program for prevention of low back pain recurrence in adults: statistical analysis plan for the WalkBack randomised controlled trial." Trials, 24, 197. https://doi.org/10.1186/s13063-023-07119-0
  20. 54.Rice, D., Nijs, J., Kosek, E., Wideman, T., et al. (2019). "Exercise-induced hypoalgesia in pain-free and chronic pain populations: state of the art and future directions." Journal of Pain, 20(11), 1249-1266. https://doi.org/10.1016/j.jpain.2019.03.005
  21. 55.National Institute for Health and Care Excellence (2021). Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management (NG206). https://www.nice.org.uk/guidance/ng206/chapter/Recommendations
  22. 27.Cherkin, D.C., Sherman, K.J., Balderson, B.H., Cook, A.J., et al. (2016). "Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial." JAMA, 315(12), 1240-1249. https://doi.org/10.1001/jama.2016.2323 (342 adults; 61% with mindfulness-based stress reduction and 58% with cognitive behavioral therapy)
  23. 56.Krause, A.J., Prather, A.A., Wager, T.D., Lindquist, M.A., and Walker, M.P. (2019). "The pain of sleep loss: a brain characterization in humans." Journal of Neuroscience, 39(12), 2291-2300. https://doi.org/10.1523/JNEUROSCI.2408-18.2018
  24. 57.Selvanathan, J., Pham, C., Nagappa, M., Peng, P.W.H., et al. (2021). "Cognitive behavioral therapy for insomnia in patients with chronic pain: a systematic review and meta-analysis of randomized controlled trials." Sleep Medicine Reviews, 60, 101460. https://doi.org/10.1016/j.smrv.2021.101460
  25. 31.Manninen, S., Tuominen, L., Dunbar, R.I., Karjalainen, T., et al. (2017). "Social laughter triggers endogenous opioid release in humans." Journal of Neuroscience, 37(25), 6125-6131. https://doi.org/10.1523/JNEUROSCI.0688-16.2017 (comedy watched with close friends released opioids in the brains of 12 men scanned with PET)
  26. 58.Coan, J.A., Schaefer, H.S., and Davidson, R.J. (2006). "Lending a hand: social regulation of the neural response to threat." Psychological Science, 17(12), 1032-1039. https://doi.org/10.1111/j.1467-9280.2006.01832.x
  27. 59.World Health Organization (2023). WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings. Geneva: WHO. https://www.ncbi.nlm.nih.gov/books/NBK599212/ (opioid analgesics are among 14 interventions WHO says should not be routinely offered for chronic primary low back pain)
  28. 60.Agnoli, A., Xing, G., Tancredi, D.J., Magnan, E., et al. (2021). "Association of dose tapering with overdose or mental health crisis among patients prescribed long-term opioids." JAMA, 326(5), 411-419. https://doi.org/10.1001/jama.2021.11013
  29. 61.Santo, T. Jr., Clark, B., Hickman, M., Grebely, J., et al. (2021). "Association of opioid agonist treatment with all-cause mortality and specific causes of death among people with opioid dependence: a systematic review and meta-analysis." JAMA Psychiatry, 78(9), 979-993. https://doi.org/10.1001/jamapsychiatry.2021.0976
  30. 62.US Food and Drug Administration (2023). FDA Approves First Over-the-Counter Naloxone Nasal Spray. https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray

This topic carries 62 notes in the research manuscript; the 30 above are those behind the material on this page. Full source register.