tag:theconversation.com,2011:/uk/topics/pain-1263/articlesPain – The Conversation2024-02-28T18:02:06Ztag:theconversation.com,2011:article/2202532024-02-28T18:02:06Z2024-02-28T18:02:06ZPersistent shoulder pain: Are exercises always necessary to relieve symptoms?<figure><img src="https://images.theconversation.com/files/566901/original/file-20231206-19-pkjjrg.jpg?ixlib=rb-1.1.0&rect=2%2C0%2C986%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The presence of pain, especially when it persists over time, is not necessarily a sign that your condition is deteriorating.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>It is estimated that <a href="https://pubmed.ncbi.nlm.nih.gov/15163107/">close to 70 per cent</a> of the population will experience shoulder pain at some point in their lives. </p>
<p>In itself, this pain would not pose a problem if it disappeared as quickly as it appeared. Unfortunately, it tends to persist over time. In half of patients, <a href="https://pubmed.ncbi.nlm.nih.gov/8806252/">the pain persists or reoccurs one year</a> after its initial appearance. It can even persist for several years in some cases.</p>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/8917870/">Approximately 70 per cent</a> of shoulder pain episodes requiring consultation with a health-care provider can be identified as <a href="https://pubmed.ncbi.nlm.nih.gov/27083390/">rotator cuff related shoulder pain</a>. This refers to pain and loss of function in the shoulder, mainly during movements requiring the arm to be lifted. Although a number of effective options are available to patients, <a href="https://pubmed.ncbi.nlm.nih.gov/10226960/">a third of them</a> will not experience any significant improvement in their condition, regardless of the interventions used. </p>
<p>There are several possible reasons for this limited success. <a href="https://academic.oup.com/ptj/article/101/7/pzab072/6145046?login=true">Exercise selection</a> and some <a href="https://bjsm.bmj.com/content/52/4/269">psychological and contextual characteristics</a> specific to each individual have been identified as potential hypotheses.</p>
<p>As experts in the field of shoulder pain, we propose to shed light on the effectiveness of various interventions for the management of shoulder pain, and the role that some variables may play in the resolution of this pain.</p>
<h2>Some important questions</h2>
<p>Our research team therefore set out to find out: </p>
<ol>
<li><p>Whether one type of exercise should be prioritized over another in the management of shoulder pain.</p></li>
<li><p>Whether the addition of exercises (the pet peeve of many people who consult a rehabilitation provider) lead to additional benefits compared with an intervention comprising only of education and advice to foster pain self-management.</p></li>
<li><p>Whether some psychological and contextual characteristics, such as participants’ expectations of the intervention effectiveness and pain self-efficacy, are associated with a better prognosis.</p></li>
</ol>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/16446108/">Pain self-efficacy</a> is the level of confidence someone has in their ability to carry out their activities and achieve their goals despite pain.</p>
<h2>How did we go about answering those questions?</h2>
<p>In our <a href="https://bjsm.bmj.com/content/57/8/457">new study</a> published in the <em>British Journal of Sports Medicine</em>, 123 people with shoulder pain lasting for more than three months were randomly assigned to one of three 12-week interventions: </p>
<ul>
<li><p>Education </p></li>
<li><p>Education combined with motor control exercises </p></li>
<li><p>Education combined with strengthening exercises </p></li>
</ul>
<p>Questionnaires were used to monitor changes in participants’ condition over time, particularly in terms of their pain and functional capacity. </p>
<p>Before the start of the intervention, we also used <a href="https://journals.lww.com/painrpts/fulltext/2021/11000/measurement_properties_of_the_pain_self_efficacy.21.aspx">questionnaires</a> to measure participants’ expectations of the effectiveness of the intervention they were about to receive, as well as their level of pain self-efficacy. </p>
<h2>The content of each group</h2>
<p><em>Education</em></p>
<p>Participants in this group received two sessions of education and advice with a physiotherapist. The information was about the shoulder and pain, and the advice included strategies for the self-management of their condition. </p>
<p>Participants were also told about the importance of being active and adopting a healthy lifestyle to optimize the management of persistent pain, including proper diet, hydration, stress management and sleep hygiene. </p>
<p>Finally, participants were asked to watch six short videos on these themes. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/5bUf9VcYLmI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Example of a video that study participants were asked to watch.</span></figcaption>
</figure>
<p>After viewing, they were asked to identify the aspects they felt were important and those that raised questions in order to discuss them with the physiotherapist.</p>
<p><em>Education combined with motor control exercises</em></p>
<p>As well as receiving this education, the participants in this group completed a 12-week exercise program. </p>
<p>The exercises included modifications in the way they performed their movements to enable them to move their arm with less pain. These modifications were integrated with exercises reproducing gestures involving the shoulder during daily activities.</p>
<p><em>Education combined with strengthening exercises</em></p>
<p>Again, participants in this group received the same education component. </p>
<p>They also received a shoulder muscle strengthening program to be performed daily for 12 weeks.</p>
<h2>The results of our study</h2>
<p><a href="https://blogs.bmj.com/bjsm/2023/04/17/does-the-addition-of-motor-control-or-strengthening-exercises-to-education-result-in-better-outcomes-for-rotator-cuff-related-shoulder-pain/">At the end of the study</a>, participants in all three groups showed improvements in pain and function. However, the addition of exercises (motor control or strengthening) to the education intervention did not lead to additional benefits. </p>
<p>People recruited into the study whose symptoms were considered resolved following the 12-week intervention had more positive expectations regarding the effectiveness of their intervention and had higher levels of pain self-efficacy. </p>
<h2>Key messages</h2>
<p>Adding strengthening or motor control exercises to an educational intervention did not result in additional benefits compared to an approach based solely on education and advice. For some people with persistent shoulder pain, education and advice focusing on pain self-management may be sufficient to promote symptom resolution. </p>
<p>Exercise, in any form, remains a highly relevant intervention for <a href="https://www.jospt.org/doi/full/10.2519/jospt.2022.11306">shoulder pain management</a>, as well as for <a href="https://bjsm.bmj.com/content/53/14/856">maintaining independence</a> and <a href="https://bjsm.bmj.com/content/57/18/1203">optimizing long-term health</a>. </p>
<p>Participants’ pain self-efficacy and expectations of the effectiveness of the intervention they receive may play a role in the prognosis of their shoulder pain. </p>
<h2>But above all…</h2>
<p>When you’re experiencing shoulder pain, it can be beneficial to temporarily reduce certain activities that can aggravate your pain. However, it’s important not to delay gradually reintegrating these activities into your daily routine. </p>
<p>The presence of pain, especially when it persists over time, <a href="https://pubmed.ncbi.nlm.nih.gov/32694387/">is not necessarily a sign that your condition is deteriorating</a>. It could simply indicate that the gestures or activities performed exceed the <a href="https://therunningclinic.com/mechanical-stress-quantification/">shoulder’s current ability to tolerate the load imposed on it</a>. </p>
<p>In any case, don’t hesitate to consult a health professional, such as a <a href="https://oppq.qc.ca/">physiotherapist</a>, who will be able to help you “shoulder” the responsibility of managing your condition.</p><img src="https://counter.theconversation.com/content/220253/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marc-Olivier Dubé is a member of the Ordre Professionnel de la Physiothérapie du Québec (OPPQ). He is the recipient of a postdoctoral fellowship from the Fonds de recherche du Québec - Santé (FRQS).</span></em></p><p class="fine-print"><em><span>Jean-Sébastien Roy received funding from Canadian Institutes of Health Research, Fonds de recherche du Québec - Santé (FRQS), Arthritis Society Canada and Natural Sciences and Engineering Research Council of Canada. </span></em></p><p class="fine-print"><em><span>François Desmeules ne travaille pas, ne conseille pas, ne possède pas de parts, ne reçoit pas de fonds d'une organisation qui pourrait tirer profit de cet article, et n'a déclaré aucune autre affiliation que son organisme de recherche.</span></em></p>Education and advice, as well as exercise, can play a role in the management of shoulder pain.Marc-Olivier Dubé, Physiothérapeute, Chercheur postdoctoral en réadaptation, Université LavalFrançois Desmeules, Professeur titulaire en physiothérapie et en santé musculosquelettique, École de réadaptation, Université Montréal, Université de MontréalJean-Sébastien Roy, Professeur titulaire à l'École des sciences de la réadaptation, Université LavalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2225132024-02-19T19:04:30Z2024-02-19T19:04:30ZHow long does back pain last? And how can learning about pain increase the chance of recovery?<figure><img src="https://images.theconversation.com/files/576603/original/file-20240219-18-edti6b.jpg?ixlib=rb-1.1.0&rect=60%2C60%2C6639%2C4406&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/upset-mature-woman-suffering-backache-after-1504807832">fizkes/Shutterstock</a></span></figcaption></figure><p>Back pain is common. One in thirteen people have it right now and worldwide a staggering 619 million people will <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186678/">have it this year</a>.</p>
<p>Chronic pain, of which back pain is the most common, is the world’s <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186678/">most disabling</a> health problem. Its economic impact <a href="https://www.ncbi.nlm.nih.gov/books/NBK92510/">dwarfs other health conditions</a>. </p>
<p>If you get back pain, how long will it take to go away? We scoured the scientific literature to <a href="https://www.cmaj.ca/content/cmaj/196/2/E29.full.pdf">find out</a>. We found data on almost 20,000 people, from 95 different studies and split them into three groups: </p>
<ul>
<li>acute – those with back pain that started less than six weeks ago</li>
<li>subacute – where it started between six and 12 weeks ago</li>
<li>chronic – where it started between three months and one year ago. </li>
</ul>
<p>We found 70%–95% of people with acute back pain were likely to recover within six months. This dropped to 40%–70% for subacute back pain and to 12%–16% for chronic back pain.</p>
<p>Clinical guidelines point to graded return to activity and pain education under the guidance of a health professional as the best ways to promote recovery. Yet these effective interventions are underfunded and hard to access.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-cognitive-functional-therapy-how-can-it-reduce-low-back-pain-and-get-you-moving-207009">What is cognitive functional therapy? How can it reduce low back pain and get you moving?</a>
</strong>
</em>
</p>
<hr>
<h2>More pain doesn’t mean a more serious injury</h2>
<p>Most acute back pain episodes are <a href="https://www.racgp.org.au/getattachment/75af0cfd-6182-4328-ad23-04ad8618920f/attachment.aspx">not caused</a> by serious injury or disease.</p>
<p>There are rare exceptions, which is why it’s wise to see your doctor or physio, who can check for signs and symptoms that warrant further investigation. But unless you have been in a significant accident or sustained a large blow, you are unlikely to have caused much damage to your spine. </p>
<figure class="align-center ">
<img alt="Factory worker deep-breathes with a sore back" src="https://images.theconversation.com/files/575505/original/file-20240214-24-yvwksc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/575505/original/file-20240214-24-yvwksc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/575505/original/file-20240214-24-yvwksc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/575505/original/file-20240214-24-yvwksc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/575505/original/file-20240214-24-yvwksc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/575505/original/file-20240214-24-yvwksc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/575505/original/file-20240214-24-yvwksc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Your doctor or physio can rule out serious damage.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/asian-man-worker-warehouse-have-accident-2181811499">DG fotostock/Shutterstock</a></span>
</figcaption>
</figure>
<p>Even very minor back injuries can be brutally painful. This is, in part, because of how we are made. If you think of your spinal cord as a very precious asset (which it is), worthy of great protection (which it is), a bit like the crown jewels, then what would be the best way to keep it safe? Lots of protection and a highly sensitive alarm system.</p>
<p>The spinal cord is protected by strong bones, thick ligaments, powerful muscles and a highly effective alarm system (your nervous system). This alarm system can trigger pain that is so unpleasant that you cannot possibly think of, let alone do, anything other than seek care or avoid movement. </p>
<p>The messy truth is that when pain persists, the pain system becomes more sensitive, so a widening array of things contribute to pain. This pain system hypersensitivity is a result of neuroplasticity – your nervous system is becoming better at making pain. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-pain-and-what-is-happening-when-we-feel-it-49040">Explainer: what is pain and what is happening when we feel it?</a>
</strong>
</em>
</p>
<hr>
<h2>Reduce your chance of lasting pain</h2>
<p>Whether or not your pain resolves is not determined by the extent of injury to your back. We don’t know all the factors involved, but we do know there are things that you can do to reduce chronic back pain:</p>
<ul>
<li><p>understand how pain really works. This will involve intentionally learning about modern pain science and care. It will be difficult but rewarding. It will help you work out what you can do to change your pain </p></li>
<li><p>reduce your pain system sensitivity. With guidance, patience and persistence, you can learn how to gradually retrain your pain system back towards normal.</p></li>
</ul>
<h2>How to reduce your pain sensitivity and learn about pain</h2>
<p>Learning about “how pain works” provides the most sustainable <a href="https://www.bmj.com/content/376/bmj-2021-067718">improvements in chronic back pain</a>. Programs that combine pain education with graded brain and body exercises (gradual increases in movement) can reduce pain system sensitivity and help you return to the life you want. </p>
<figure class="align-center ">
<img alt="Physio helps patient use an exercise strap" src="https://images.theconversation.com/files/575501/original/file-20240214-22-gzb0hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/575501/original/file-20240214-22-gzb0hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/575501/original/file-20240214-22-gzb0hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/575501/original/file-20240214-22-gzb0hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/575501/original/file-20240214-22-gzb0hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=506&fit=crop&dpr=1 754w, https://images.theconversation.com/files/575501/original/file-20240214-22-gzb0hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=506&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/575501/original/file-20240214-22-gzb0hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=506&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Some programs combine education with gradual increases in movement.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-physiotherapist-exercising-senior-patient-physic-2130321380">Halfpoint/Shutterstock</a></span>
</figcaption>
</figure>
<p>These programs have been in development for years, but high-quality clinical trials <a href="https://jamanetwork.com/journals/jama/fullarticle/2794765">are now emerging</a> and it’s good news: they show most people with chronic back pain improve and many completely recover.</p>
<p>But most clinicians aren’t equipped to deliver these effective programs – <a href="https://www.jpain.org/article/S1526-5900(23)00618-1/fulltext">good pain education</a> is not taught in most medical and health training degrees. Many patients still receive ineffective and often risky and expensive treatments, or keep seeking temporary pain relief, hoping for a cure. </p>
<p>When health professionals don’t have adequate pain education training, they can deliver bad pain education, which leaves patients feeling like they’ve just <a href="https://www.jpain.org/article/S1526-5900(23)00618-1/fulltext">been told it’s all in their head</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opioids-dont-relieve-acute-low-back-or-neck-pain-and-can-result-in-worse-pain-new-study-finds-203244">Opioids don't relieve acute low back or neck pain – and can result in worse pain, new study finds</a>
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</em>
</p>
<hr>
<p>Community-driven not-for-profit organisations such as <a href="https://www.painrevolution.org/">Pain Revolution</a> are training health professionals to be good pain educators and raising awareness among the general public about the modern science of pain and the best treatments. Pain Revolution has partnered with dozens of health services and community agencies to train more than <a href="https://www.painrevolution.org/find-a-lpe">80 local pain educators</a> and supported them to bring greater understanding and improved care to their colleagues and community. </p>
<p>But a broader system-wide approach, with government, industry and philanthropic support, is needed to expand these programs and fund good pain education. To solve the massive problem of chronic back pain, effective interventions need to be part of standard care, not as a last resort after years of increasing pain, suffering and disability.</p><img src="https://counter.theconversation.com/content/222513/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sarah Wallwork receives payments for lectures on pain and rehabilitation. Sarah was funded by an NHMRC Investigator Grant awarded to GL Moseley (ID 1178444).</span></em></p><p class="fine-print"><em><span>Lorimer Moseley has received support from: Reality Health, ConnectHealth UK, Institutes of Health California, AIA Australia, Workers’ Compensation Boards and professional sporting organisations in Australia, Europe, South and North America. Professional and scientific bodies have reimbursed him for travel costs related to presentation of research on pain and pain education at scientific conferences/symposia. He has received speaker fees for lectures on pain, pain education and rehabilitation. He receives royalties for books on pain and pain education. He is non-paid CEO of the non-profit Pain Revolution, an unpaid Director of Painaustralia and an unpaid Director of Australian Pain Solutions Research Alliance.</span></em></p>Back pain is common. One in thirteen people have it right now and worldwide a staggering 619 million people will have it this year. Chronic pain, of which back pain is the most common, is the world’s most…Sarah Wallwork, Post-doctoral Researcher, University of South AustraliaLorimer Moseley, Professor of Clinical Neurosciences and Foundation Chair in Physiotherapy, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2217472024-01-31T19:08:10Z2024-01-31T19:08:10ZA new government inquiry will examine women’s pain and treatment. How and why is it different?<figure><img src="https://images.theconversation.com/files/572314/original/file-20240131-25-o9jwvw.jpg?ixlib=rb-1.1.0&rect=25%2C12%2C4228%2C2812&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/older-woman-massaging-tensed-rubbing-muscles-2365171835">Shutterstock</a></span></figcaption></figure><p>The Victorian government has announced an <a href="https://www.health.vic.gov.au/inquiry-into-womens-pain">inquiry</a> into women’s pain. Given women are disproportionately affected by pain, such a thorough investigation is long overdue. </p>
<p>The inquiry, the first of its kind in Australia and the first we’re aware of internationally, is expected to take a year. It aims to improve care and services for Victorian girls and women experiencing pain in the future.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/there-is-overwhelming-gender-bias-in-the-ndis-and-the-review-doesnt-address-it-220042">There is overwhelming gender bias in the NDIS – and the review doesn't address it</a>
</strong>
</em>
</p>
<hr>
<h2>The gender pain gap</h2>
<p>Globally, more women report chronic pain than men do. A survey of over 1,750 Victorian women found 40% are living with chronic <a href="https://www.premier.vic.gov.au/gender-pain-gap-revealed-and-women-arent-surprised">pain</a>. </p>
<p>Approximately <a href="https://pubmed.ncbi.nlm.nih.gov/36038207/#:%7E:text=About%20half%20of%20chronic%20pain,a%20higher%20prevalence%20in%20men.">half of chronic pain conditions</a> have a higher prevalence in women compared to men, including <a href="https://academic.oup.com/painmedicine/article/22/2/382/5961453">low back pain</a> and <a href="https://www.mdpi.com/2077-0383/10/14/3178">osteoarthritis</a>. And female-specific pain conditions, such as endometriosis, are much more common than male-specific pain conditions such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3894747/">chronic prostatitis/chronic pelvic pain syndrome</a>. </p>
<p>These statistics are seen <a href="https://www.abs.gov.au/statistics/health/health-conditions-and-risks/stressors-and-bodily-pain/latest-release">across the lifespan</a>, with higher rates of chronic pain being reported in females <a href="https://www.sciencedirect.com/science/article/pii/S0304395911004751?casa_token=fDkFvlrL930AAAAA:SonUMuMgqohViJ2Ok9gGQ7K4G0hChxZYolroR7t5LVSd_uzMnSe_2EBZ4b8blh3GscewZ1bI7Ac">as young as two years old</a>. This discrepancy <a href="https://www.aihw.gov.au/reports/chronic-disease/chronic-pain-in-australia/summary">increases with age</a>, with 28% of Australian women aged over 85 experiencing chronic pain compared to 18% of men. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500">People with endometriosis and PCOS wait years for a diagnosis – attitudes to women’s pain may be to blame</a>
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</em>
</p>
<hr>
<h2>It feels worse</h2>
<p>Women also experience pain differently to men. There is some evidence to suggest that when diagnosed with the same condition, women are more likely to report <a href="https://www.sciencedirect.com/science/article/pii/S1526590011008728">higher pain scores than men</a>. </p>
<p>Similarly, there is some evidence to suggest women are also more likely to report higher pain scores during experimental trials where the same painful pressure stimulus is applied to <a href="https://www.sciencedirect.com/science/article/pii/S0304395911007019?casa_token=ZK8PjH4pXUYAAAAA:UI8K8sKlrWM3OCC7qBucplrA-mct4EU5NZUpQsLQ6WooNWlfxC6MCtTdTKmtyQYjh9kcE08okiQ">both women and men</a>. </p>
<p>Pain is also more burdensome for women. Depression is twice as prevalent in women with chronic pain <a href="https://www.sciencedirect.com/science/article/pii/S0033318207710022">than men with chronic pain</a>. Women are also more likely to report <a href="https://journals.lww.com/spinejournal/FullText/2007/05200/Sex_Differences_in_Consequences_of_Musculoskeletal.17.aspx?casa_token=mgToFxqQuiwAAAAA:Plx0N_ILNIVK_D8NDODFYaYi_HDxbZN2enulMAS0VmIwyCNHd3c62lhEDi_AYDw8Dhz7uX2dPIZ3HoqwnuWoanLH">more health care use</a> and be <a href="https://www.aihw.gov.au/getmedia/10434b6f-2147-46ab-b654-a90f05592d35/aihw-phe-267.pdf.aspx">hospitalised due to their pain</a> than men. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman lies in bed in pain" src="https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/572316/original/file-20240131-16-pjgp8g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Women seem to feel pain more acutely and often feel ignored by doctors.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-having-stomach-ache-on-1780468907">Shutterstock</a></span>
</figcaption>
</figure>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-a-tens-machine-can-it-help-my-period-pain-or-endometriosis-201389">What's a TENS machine? Can it help my period pain or endometriosis?</a>
</strong>
</em>
</p>
<hr>
<h2>Medical misogyny</h2>
<p>Women in pain are viewed and treated differently to men. Women are more likely to be told their pain is psychological and dismissed as <a href="https://www.tandfonline.com/doi/full/10.1080/03630242.2017.1306606?casa_token=twusk7mU5EcAAAAA%3AG--5Y_nl_bDqsR9k4w-fF8sEMGuGiMlrifAGQKC_j6swOBhYdzzwXeXiNUoR4C9vM2CydSppwLN2">not being real or “all in their head”</a>.</p>
<p>Hollywood actor <a href="https://www.independent.co.uk/life-style/health-and-families/selma-blair-ms-misdiagnosis-symptoms-b2454317.html">Selma Blair</a> recently shared her experience of having her symptoms repeatedly dismissed by doctors and put down to “menstrual issues”, before being diagnosed with multiple sclerosis in 2018. </p>
<p>It’s an experience familiar to many women in Australia, where medical misogyny still runs deep. <a href="https://journals.sagepub.com/doi/abs/10.1177/09593535221083846?journalCode=fapa&">Our research</a> has repeatedly shown Australian women with pelvic pain are similarly dismissed, leading to lengthy diagnostic delays and serious impacts on their quality of life. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1752111921006797065"}"></div></p>
<h2>Misogyny exists in research too</h2>
<p>Historically, misogyny has also run deep in medical research, including pain research. Women have been viewed as smaller bodied men with different reproductive <a href="https://www.sciencedirect.com/science/article/abs/pii/S156925580334024X">functions</a>. As a result, most pre-clinical pain research has used male rodents as the default research <a href="https://journals.lww.com/pain/fulltext/2005/09000/the_case_for_the_inclusion_of_female_subjects_in.1.aspx?casa_token=BcqYDDSRxo4AAAAA:nLvLqpNfuwSm6N4n1kn-Wcj4n9HW__ISaNz57PYp0zX8Nfu9a5cWZdJkjCXVXeU_HKjraI5NbND-rqqzanYuF864">subject</a>. Some researchers say the menstrual cycle in female rodents adds additional variability and therefore uncertainty to experiments. And while variability due to the menstrual cycle may be true, it may be no greater than male-specific sources of variability (such as within-cage aggression and dominance) that can also <a href="https://www.nature.com/articles/s41583-020-0310-6">influence research findings</a>. </p>
<p>The exclusion of female subjects in pre-clinical studies has hindered our understanding of sex differences in pain and of response to treatment. Only recently have we begun to understand various genetic, neurochemical, and neuroimmune factors contribute to sex differences in <a href="https://www.annualreviews.org/doi/full/10.1146/annurev-neuro-092820-105941">pain prevalence and sensitivity</a>. And sex differences exist in pain processing itself. For instance, in the spinal cord, male and female rodents process <a href="https://theconversation.com/pain-really-is-in-the-mind-but-not-in-the-way-you-think-1151">potentially painful stimuli</a> through <a href="https://www.nature.com/articles/nn.4053">entirely different immune cells</a>. </p>
<p>These differences have relevance for how pain should be treated in women, yet many of the existing pharmacological treatments for pain, including opioids, are largely or solely based upon research completed on male rodents. </p>
<p>When women seek care, their pain is also treated differently. Studies show women receive <a href="https://link.springer.com/article/10.1007/s11916-023-01135-0#ref-CR6">less pain medication after surgery compared to men</a>. In fact, one study found while men were prescribed opioids after joint surgery, women were <a href="https://link.springer.com/article/10.1007/s11916-023-01135-0#ref-CR17">more likely to be prescribed antidepressants</a>. In another study, women were more likely to receive sedatives for pain relief following surgery, while men were <a href="https://link.springer.com/content/pdf/10.1007/BF00289259.pdf">more likely to receive pain medication</a>. </p>
<p>So, women are disproportionately affected by pain in terms of how common it is and sensitivity, but also in how their pain is viewed, treated, and even researched. Women continue to be excluded, dismissed, and receive sub-optimal care, and the recently announced inquiry aims to improve this. </p>
<h2>What will the inquiry involve?</h2>
<p>Consumers, health-care professionals and health-care organisations will be invited to share their experiences of treatment services for women’s pain in Victoria as part of the year-long inquiry. These experiences will be used to describe the current service delivery system available to Victorian women with pain, and to plan more appropriate services to be delivered in the future. </p>
<p>Inquiry <a href="https://www.health.vic.gov.au/public-health/inquiry-into-womens-pain-submissions">submissions</a> are now open until March 12 2024. If you are a Victorian woman living with pain, or provide care to Victorian women with pain, we encourage you to submit.</p>
<p>The state has an excellent track record of improving women’s health in many areas, including <a href="https://www.premier.vic.gov.au/groundbreaking-clinic-improving-womens-heart-health">heart</a>, <a href="https://www.health.vic.gov.au/publications/victorian-womens-sexual-and-reproductive-health-plan-2022-30">sexual, and reproductive health</a>, but clearly, we have a way to go with women’s pain. We wait with bated breath to see the results of this much-needed investigation, and encourage other states and territories to take note of the findings.</p><img src="https://counter.theconversation.com/content/221747/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jane Chalmers receives funding from The Hospital Research Foundation. </span></em></p><p class="fine-print"><em><span>Amelia Mardon does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women are disproportionately affected by pain in terms of how common it is and sensitivity, but also in how their pain is viewed, treated, and even researched.Jane Chalmers, Senior Lecturer in Pain Sciences, University of South AustraliaAmelia Mardon, PhD Candidate, University of South AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2208292024-01-19T18:09:40Z2024-01-19T18:09:40ZSix surprising things about placebos everyone should know<figure><img src="https://images.theconversation.com/files/569889/original/file-20240117-27-yzesqg.jpg?ixlib=rb-1.1.0&rect=97%2C14%2C4880%2C2552&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/medicine-placebo-box-drugs-3d-illustration-1064571812">esoxx/Shutterstock</a></span></figcaption></figure><p>Placebos have been studied more than any treatment in the history of medicine, yet they remain mysterious. </p>
<p>I’ve been studying placebos for 20 years and I’ve done some of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6288933/">key studies</a> that have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3655171/">advanced the scientific knowledge</a> in this area. Here are six facts about this strange effect that still fascinate me.</p>
<h2>1. Placebos have a dark cousin: nocebos</h2>
<p>A 29-year-old builder went to the hospital after having jumped onto a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5471339/">15cm nail</a> that pierced his boot. Moving the nail was so painful he had to be sedated with powerful drugs (fentanyl and midazolam) to remove it. But when he took off his boot, the medics discovered that the nail had gone between his toes. The builder’s pain was caused by the wrong belief that the nail had penetrated his foot. </p>
<p>The detrimental effects of negative expectations are called nocebo effects. For evolutionary reasons (survival depends on avoiding danger), nocebo effects are larger than placebo effects. </p>
<p>Unfortunately, patients are often told more about the bad things that might happen than the good things, which can result in a self-fulfilling prophecy. For example, learning that a drug has a possible side-effect of nausea or pain can actually <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7368797/">cause nausea or pain</a>.</p>
<figure class="align-center ">
<img alt="A builder about to step on a nail" src="https://images.theconversation.com/files/570058/original/file-20240118-15-d5qvgd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/570058/original/file-20240118-15-d5qvgd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/570058/original/file-20240118-15-d5qvgd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/570058/original/file-20240118-15-d5qvgd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/570058/original/file-20240118-15-d5qvgd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/570058/original/file-20240118-15-d5qvgd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/570058/original/file-20240118-15-d5qvgd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The nocebo effect is much stronger than the placebo effect.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/construction-worker-has-accident-while-walks-1398989114">Gustavo MS_Photography/Shutterstock</a></span>
</figcaption>
</figure>
<h2>2. Placebos work even if people know they are placebos</h2>
<p>Linda Buonanno suffered so badly from irritable bowel syndrome that she often couldn’t <a href="https://www.theguardian.com/lifeandstyle/2017/may/22/knew-they-were-sugar-pills-felt-fantastic-rise-open-label-placebos">leave the house</a> for weeks. She signed up for a trial of “honest” (open-label) placebos, which is a placebo that patients know is a placebo. </p>
<p>The Harvard doctors in the trial <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008733/">told her</a> the pills were “placebo pills made of an inert substance, like sugar pills, that have been shown in clinical studies to produce significant improvement in [irritable bowel] symptoms through mind-body self-healing processes”.</p>
<p>The honest placebos worked so well that she was able to resume a normal life. </p>
<p>Honest placebos have <a href="https://pubmed.ncbi.nlm.nih.gov/28452193/">worked in other trials</a> for treating depression, back pain and attention deficit hyperactivity disorder (ADHD). </p>
<p>Honest placebos work because of our subconscious expectations. Our past experiences of doctors and hospitals can generate subconscious expectations that activate our body’s inner pharmacy, which produces morphine (endorphins) and other beneficial drugs. </p>
<h2>3. Honest placebos are ethically acceptable</h2>
<p>It is often considered unethical for doctors to give placebos to patients because this supposedly <a href="https://link.springer.com/article/10.1007/s11724-014-0400-1">involves lying</a> (telling patients that a sugar pill is a powerful medication). But honest placebos do not involve lying, so there is no ethical barrier. </p>
<p>In one <a href="https://pubmed.ncbi.nlm.nih.gov/34805194/#:%7E:text=Introduction%3A%20Open%2Dlabel%20placebos%20have,label%20placebos%20in%20acute%20pain.">ongoing trial</a>, doctors asked patients whether they would be willing to try a mix of real painkillers and honest placebos. Patients in this trial have the same level of pain relief following surgery, but are less likely to become dependent on painkillers.</p>
<h2>4. Placebo effects are part of most treatment effects</h2>
<p>When a doctor prescribes ibuprofen for back pain, the effects are due to the ibuprofen and the patient’s beliefs and expectations, which can be influenced by the doctor’s communication. Doctors who offer positive messages in a warm, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6047264/">empathic manner</a> will increase the effect of the drugs. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2359128/">size and colour</a> of the pill can also influence the effect. A large, orange pill can reduce pain more than a small, red one. </p>
<p>By contrast, blue pills generally have a sedative effect – except for Italian men, for whom blue pills have an <a href="https://www.amherst.edu/system/files/media/1601/moerman_explanatory%20mechanisms%20for%20placebo%20effects.pdf">excitative effect</a>), probably because their revered football team wears blue. </p>
<p>Doctors’ ethical duty to benefit patients suggests it is an ethical duty to maximise the placebo effects of all treatments they provide.</p>
<h2>5. You don’t need placebos to have placebo effects</h2>
<p>In one trial, patients were given morphine <a href="https://pubmed.ncbi.nlm.nih.gov/15488461/">via an intravenous line</a> following surgery. However, only half of the patients were told they were receiving morphine. The patients who were told this had 50% more pain relief than those who were not told they were receiving morphine. This is an example of a placebo effect without a placebo.</p>
<h2>6. You can generate placebo (and nocebo) effects in yourself</h2>
<p>All communication can have a beneficial or harmful effect. One study found that teaching communication skills to families <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4915212/">reduced anxiety and depression</a>. On the other hand, couples who dwell on problems and negative aspects of their relationships were shown in a study to have <a href="https://www.sciencedirect.com/science/article/abs/pii/S0306453022003304?via%3Dihub">weaker immune systems</a>. </p>
<p>Acts of altruism, focusing on a brighter future, or gratitude are proven ways to reduce the effect of negative communication. An easy way to generate positive placebo effects for yourself is by performing a <a href="https://www.mentalhealth.org.uk/explore-mental-health/kindness-and-mental-health/random-acts-kindness">random act of kindness</a>, such as making a colleague a cup of tea, or simply smiling and saying hello.</p>
<p>You can learn more about the amazing effects of placebos and nocebos in my <a href="https://www.press.jhu.edu/books/title/12830/power-placebos">latest book</a>, The Power of Placebos: How the Science of Placebos and Nocebos can Improve Health Care.</p><img src="https://counter.theconversation.com/content/220829/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeremy Howick has received funding from the Medical Research Council (MRC), National Institute for Health and Care Research (NIHR), the General Medical Council (GMC). He is currently funded by the Stoneygate Trust.</span></em></p>Placebos are the closest thing to magic that medicine has discovered.Jeremy Howick, Professor and Director of the Stoneygate Centre for Excellence in Empathic Healthcare, University of LeicesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2183442023-12-21T23:19:57Z2023-12-21T23:19:57ZGot period pain or cramps? What to eat and avoid, according to science<figure><img src="https://images.theconversation.com/files/566750/original/file-20231219-27-7x7oaq.jpg?ixlib=rb-1.1.0&rect=1%2C1%2C1276%2C848&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-suffering-from-a-stomach-pain-5938362/">Sora Shimazaki/Pexels</a></span></figcaption></figure><p>Painful periods are common. More than half of people who menstruate have some pain for up to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8943241/">three days a month</a>, typically throbbing or cramping in the lower abdomen. </p>
<p>Digestive changes – such as vomiting, gas, bloating, diarrhoea and a “bubbling gut” – are also <a href="https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-018-0538-8">common</a> around the time of menstruation. </p>
<p>There are many <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8943241/">treatments</a> for period pain (known medically as dysmenorrhoea). Not all these treatments are well-tolerated or work for everyone.</p>
<p>We’re learning more about food’s role in influencing <a href="https://theconversation.com/9-signs-you-have-inflammation-in-your-body-could-an-anti-inflammatory-diet-help-210468">inflammation</a> in our body. So, could eating or avoiding certain foods <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5963185/">help</a> with painful periods? Here’s what we know based on high-quality research.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-sharp-butt-pains-to-period-poos-5-lesser-known-menstrual-cycle-symptoms-191352">From sharp butt pains to period poos: 5 lesser-known menstrual cycle symptoms</a>
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</p>
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<h2>Foods that may relieve period pain or cramps</h2>
<p><strong>Foods containing omega-3 fatty acids</strong></p>
<p>Foods rich in omega-3 fatty acids include chia seeds, walnuts, flaxseeds, salmon, herring, sardines, mackerel, oysters and edamame beans. Omega-3 fatty acids are naturally present in oils including fish, cod liver, algal, krill, flaxseed (linseed), soybean and canola oils.</p>
<p>Omega-3 fatty acids <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3257651/">affect</a> how our cells function and the signalling pathways associated with inflammation and pain. </p>
<p>Earlier this year, researchers published a <a href="https://pubmed.ncbi.nlm.nih.gov/37545015/#:%7E:text=Meta%2Danalysis%20(n%20%3D%208,0.51)%20at%20reducing%20dysmenorrhoea%20pain.">meta-analysis</a> where they combined and analysed all data available on the impact of omega-3 fatty acids on period pain. They found diets high in omega-3 fatty acids (including supplements of 300-1,800 milligrams a day) over two to three months may reduce pain, and pain medication use, in people with painful periods.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/566754/original/file-20231219-15-vu9xne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Open sardine can, parsley, cut lemon on wooden table." src="https://images.theconversation.com/files/566754/original/file-20231219-15-vu9xne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566754/original/file-20231219-15-vu9xne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566754/original/file-20231219-15-vu9xne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566754/original/file-20231219-15-vu9xne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566754/original/file-20231219-15-vu9xne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566754/original/file-20231219-15-vu9xne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566754/original/file-20231219-15-vu9xne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Sardines and other oily fish are rich in omega-3 fatty acids.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/open-can-sardines-preserves-oil-on-1636046179">BearFotos/Shutterstock</a></span>
</figcaption>
</figure>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/are-fish-oil-supplements-as-healthy-as-we-think-and-is-eating-fish-better-212250">Are fish oil supplements as healthy as we think? And is eating fish better?</a>
</strong>
</em>
</p>
<hr>
<p><strong>Foods high in vitamin D</strong></p>
<p>Foods high in vitamin D include trout, salmon, tuna and mackerel, as well as fish liver oils. Small amounts are also found in beef liver, egg yolk and cheese. Mushrooms contain varying levels of vitamin D, and you can <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6213178/">boost</a> this by exposing them to direct midday sunlight for 15-120 minutes. </p>
<p>The body can make vitamin D when it gets sunlight exposure and you can also get vitamin D from supplements.</p>
<p>Vitamin D <a href="https://pubmed.ncbi.nlm.nih.gov/24262718/">may help</a> reduce the factors that cause inflammation in the uterus. This includes levels of hormone-like molecules called prostaglandins. </p>
<p>A 2023 <a href="https://www.mdpi.com/2072-6643/15/13/2830#B11-nutrients-15-02830">meta-analysis</a> showed women who received weekly doses of vitamin D greater than 50,000 IU (or international units) had relief from period pain, regardless of how long and how often women took the vitamin.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/should-i-be-getting-my-vitamin-d-levels-checked-211268">Should I be getting my vitamin D levels checked?</a>
</strong>
</em>
</p>
<hr>
<p><strong>Foods high in vitamin E</strong></p>
<p>Foods rich in vitamin E include seeds (particularly sunflower seeds), nuts (particularly almonds, hazelnuts and peanuts) and spinach, broccoli, kiwifruit, mango and tomato. </p>
<p>There is some evidence vitamin E supplements reduce period pain. In a well-conducted <a href="https://pubmed.ncbi.nlm.nih.gov/15777446/">trial</a> run over the course of four periods, women took vitamin E supplements (90 milligrams, twice a day) for five days, beginning two days before the expected start of the period. This significantly reduced the severity and duration of period pain. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/566756/original/file-20231220-17-d2da5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman tipping out nut mix into palm of hand" src="https://images.theconversation.com/files/566756/original/file-20231220-17-d2da5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566756/original/file-20231220-17-d2da5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566756/original/file-20231220-17-d2da5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566756/original/file-20231220-17-d2da5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566756/original/file-20231220-17-d2da5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566756/original/file-20231220-17-d2da5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566756/original/file-20231220-17-d2da5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Seeds and nuts are rich in vitamin E.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hands-holding-jar-nuts-dried-fruits-1112521214">NazarBazar/Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-have-painful-periods-could-it-be-endometriosis-101026">I have painful periods, could it be endometriosis?</a>
</strong>
</em>
</p>
<hr>
<h2>Foods that may worsen period pain or cramps</h2>
<p><strong>Highly processed foods</strong></p>
<p>Highly processed foods include energy-dense, nutrient-poor foods such as takeaways, chips, biscuits, doughnuts, processed meats and soft drinks. </p>
<p>Research findings on the impact of a diet high in processed foods on period pain vary. A 2019 <a href="https://karger.com/goi/article/84/3/209/153726/Nutrition-as-a-Potential-Factor-of-Primary">review</a> found sugar consumption had little association with painful periods. </p>
<p>However, some observational studies (which do not involve an intervention) suggest women who eat more processed foods may have more intense period pain. For example, a <a href="https://pubmed.ncbi.nlm.nih.gov/19468949/">2009 study</a> found adolescent females who ate fast or processed foods for two days or more a week reported more period pain compared with those who did not. Therefore, eating less processed food may be something to consider. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/8-everyday-foods-you-might-not-realise-are-ultra-processed-and-how-to-spot-them-197993">8 everyday foods you might not realise are ultra processed – and how to spot them</a>
</strong>
</em>
</p>
<hr>
<p><strong>Caffeine</strong></p>
<p>Foods high in caffeine include coffee, energy drinks and some processed energy bars. Caffeine intake is <a href="https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwij7LmPxfSCAxV5d_UHHRnyDyUQFnoECBIQAQ&url=https%3A%2F%2Fwww.ncbi.nlm.nih.gov%2Fpmc%2Farticles%2FPMC4222008%2F&usg=AOvVaw2mEjyMadOB1D6geQgAwckc&opi=89978449">associated with</a> menstrual pain. </p>
<p>Although we don’t know the precise underlying mechanism, researchers think caffeine may narrow blood vessels, which limits blood flow, leading to stronger cramps.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/566757/original/file-20231220-23-u1d2j2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Tired woman staring at bowl of breakfast, cereal and cup on kitchen table" src="https://images.theconversation.com/files/566757/original/file-20231220-23-u1d2j2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/566757/original/file-20231220-23-u1d2j2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566757/original/file-20231220-23-u1d2j2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566757/original/file-20231220-23-u1d2j2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566757/original/file-20231220-23-u1d2j2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566757/original/file-20231220-23-u1d2j2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566757/original/file-20231220-23-u1d2j2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Avoiding coffee may help your period pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/woman-does-not-want-eat-her-151886987">Lolostock/Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/nope-coffee-wont-give-you-extra-energy-itll-just-borrow-a-bit-that-youll-pay-for-later-197897">Nope, coffee won't give you extra energy. It'll just borrow a bit that you'll pay for later</a>
</strong>
</em>
</p>
<hr>
<p><strong>Alcohol</strong></p>
<p>Drinking alcohol is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859868/">not</a> a recognised risk factor for painful periods. However, chronic heavy alcohol use reduces levels of <a href="https://academic.oup.com/alcalc/article/55/2/164/5734241">magnesium</a> in the blood. Magnesium is an important factor in relaxing muscles and supporting blood flow.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/adele-called-herself-a-borderline-alcoholic-but-is-that-a-real-thing-215987">Adele called herself a 'borderline alcoholic'. But is that a real thing?</a>
</strong>
</em>
</p>
<hr>
<h2>A healthy, balanced diet is your best best</h2>
<p>Having a healthy, balanced diet is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7071223/">one of the best ways</a> we can support our own health and prevent future chronic conditions. This can help reduce inflammation in our bodies, thought to be the main way diet can help people with painful periods.</p>
<p>If you are looking for tailored dietary advice or a menstrual health meal plan, speak with an <a href="https://member.dietitiansaustralia.org.au/Portal/Portal/Search-Directories/Find-a-Dietitian.aspx">accredited practising dietitian</a>.</p>
<p>It’s important to stress, however, that diet alone cannot treat all forms of menstrual pain. So if you are concerned about your painful periods, check in with your GP who can discuss your options.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/9-signs-you-have-inflammation-in-your-body-could-an-anti-inflammatory-diet-help-210468">9 signs you have inflammation in your body. Could an anti-inflammatory diet help?</a>
</strong>
</em>
</p>
<hr>
<p><em>This article has been updated to reflect the correct date of a review that found sugar consumption had little association with painful periods.</em></p><img src="https://counter.theconversation.com/content/218344/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lauren Ball works for The University of Queensland and receives funding from the National Health and Medical Research Council, Queensland Health and Mater Misericordia. She is a Director of Dietitians Australia, a Director of the Darling Downs and West Moreton Primary Health Network and an Associate Member of the Australian Academy of Health and Medical Sciences.</span></em></p><p class="fine-print"><em><span>Emily Burch is an Accredited Practising Dietitian and member of Dietitians Australia. She works for Southern Cross University. </span></em></p><p class="fine-print"><em><span>Pui Ting Wong is a PhD Candidate at The University Queensland (UQ) Centre for Community Health and Wellbeing, and receives the UQ Tuition Fee Offset and Stipend Scholarship. She is also an Accredited Practising Dietitian and a member of Dietitians Australia.</span></em></p>A cup of coffee might help you kick-start your day, but it may actually make painful periods worse. Here’s what else to avoid (and eat) if you have period pain.Lauren Ball, Professor of Community Health and Wellbeing, The University of QueenslandEmily Burch, Lecturer, Southern Cross UniversityPui Ting Wong, PhD Candidate, culinary education and adolescent mental health, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2164452023-11-15T02:02:29Z2023-11-15T02:02:29ZWhat is the PanaNatra line of painkillers and can herbal products effectively relieve pain?<p>In an era where <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3201926/#:%7E:text=Globally%2C%20it%20has%20been%20estimated,pain%20each%20year%20%5B1%5D">chronic pain affects millions worldwide</a>, the search for effective and safe pain relief has never been greater. </p>
<p><a href="https://www.pananatra.com.au/products/">PanaNatra</a> is a line of herbal products from <a href="https://www.haleon.com/">Haleon</a>, the makers of Panadol. Haleon <a href="https://www.pananatra.com.au/products/">claims</a> the three PanaNatra’s products, made from plant extracts, help manage and provide relief from mild joint aches, mild muscle pain, and mild pain affecting sleep. </p>
<p>They contain different combinations of four plants:</p>
<ul>
<li><em>Boswellia serrata</em> (contained in the joint and muscle products) </li>
<li><em>Curcuma longa</em> (in the joint and muscle products)</li>
<li><em>Piper nigrum</em> (just in the joint product)</li>
<li><em>Withania somnifera</em> (just in the sleep product).</li>
</ul>
<p>These products are “<a href="https://www.tga.gov.au/products/medicines/non-prescription-medicines/listed-medicines">listed medicines</a>” in Australia. This means the ingredients are considered broadly low risk, have been used in traditional medicine, and are manufactured to a high standard. But the manufacturer has not provided evidence to the government regulator that they work. </p>
<p>So can herbal ingredients effectively and safely relieve different types of pain? </p>
<h2>What does the evidence say?</h2>
<p>Let’s consider the evidence for the four main ingredients.</p>
<p><strong><em>Boswellia serrata</em></strong></p>
<p>Indian Frankincense (<em>Boswellia serrata</em>) has been described in traditional Indian Ayurveda texts since the 1st century AD. Key active compounds derived from the gum resin of the tree called <a href="https://pubmed.ncbi.nlm.nih.gov/27671822/">boswellic acids</a> are thought to have anti-inflammatory effects. </p>
<figure class="align-center ">
<img alt="Boswellia serrata" src="https://images.theconversation.com/files/559173/original/file-20231113-25-2pl3tb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/559173/original/file-20231113-25-2pl3tb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/559173/original/file-20231113-25-2pl3tb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/559173/original/file-20231113-25-2pl3tb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/559173/original/file-20231113-25-2pl3tb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/559173/original/file-20231113-25-2pl3tb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/559173/original/file-20231113-25-2pl3tb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"><em>Boswellia serrata</em> is also known as Indian Frankincense.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/boswellia-serrata-73147612">Shutterstock</a></span>
</figcaption>
</figure>
<p>The <em>Boswellia serrata</em> dry concentrate extract (Rhuleave K) used in the Muscle Pain product contains 50 mg of the herb per tablet, whereas the Joint Pain product includes 33.3 mg as a different formulation (Apresflex).</p>
<p>A review of various human clinical trials using a range of formulations of this herb <a href="https://www-ncbi-nlm-nih-gov.ezproxy.library.sydney.edu.au/pmc/articles/PMC7368679/pdf/12906_2020_Article_2985.pdf">supports its ability</a> to reduce some types of pain and improve function in osteoarthritis. But a key finding of the study was that improvement only begins when <em>Boswellia serrata</em> is used continuously for four weeks and at a dose of at least 100–250 mg per day.</p>
<p>In a <a href="https://pubmed.ncbi.nlm.nih.gov/21060724/">clinical trial</a>, 100 mg daily of a <em>Boswellia serrata</em> gum-based product was found to reduce pain and improve physical functions for people with osteoarthritis.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/9-signs-you-have-inflammation-in-your-body-could-an-anti-inflammatory-diet-help-210468">9 signs you have inflammation in your body. Could an anti-inflammatory diet help?</a>
</strong>
</em>
</p>
<hr>
<p><strong><em>Curcuma longa</em></strong></p>
<p>Turmeric (<em>Curcuma longa</em>) has been used in Chinese and Indian medicine for at least 2,000 years. It contains a well-known chemical called curcumin, a natural compound used for its anti-inflammatory properties, especially for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8273926/">osteoarthritis</a>. </p>
<figure class="align-center ">
<img alt="Turmeric root (Curcuma longa)" src="https://images.theconversation.com/files/559174/original/file-20231113-17-p914do.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/559174/original/file-20231113-17-p914do.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/559174/original/file-20231113-17-p914do.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/559174/original/file-20231113-17-p914do.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/559174/original/file-20231113-17-p914do.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/559174/original/file-20231113-17-p914do.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/559174/original/file-20231113-17-p914do.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"><em>Curcuma longa</em> is also known as turmeric.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/turmeric-root-curcuma-longaherb-plant-786438259">Shutterstock</a></span>
</figcaption>
</figure>
<p>Turmeric compounds such as curcumin are <a href="https://journals.sagepub.com/doi/10.1177/1759720X221124545">often combined</a> with <em>Boswellia serrata</em> compounds to improve their anti-inflammatory effects to reduce pain. </p>
<p>A <a href="https://pubmed.ncbi.nlm.nih.gov/33511486/">review of 16 different clinical trials</a> found turmeric extracts were effective for knee osteoarthritis. </p>
<p>A similar conclusion was drawn from a <a href="https://www.sciencedirect.com/science/article/pii/S0965229921001163">review of 11 clinical trials</a> which examined the use of curcuminoids (of which curcumin is one) for one to four months. It found curcuminoids had similar pain-relieving qualities as non-steroidal anti-inflammatory based drugs. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/these-5-foods-are-claimed-to-improve-our-health-but-the-amount-wed-need-to-consume-to-benefit-is-a-lot-116730">These 5 foods are claimed to improve our health. But the amount we'd need to consume to benefit is... a lot</a>
</strong>
</em>
</p>
<hr>
<p><strong><em>Piper nigrum</em></strong></p>
<p>Black pepper (<em>Piper nigrum</em>) contains the chemical <a href="https://www.mdpi.com/2076-3417/9/20/4270">piperine</a>, which has anti-inflammatory properties.</p>
<figure class="align-center ">
<img alt="Piper Nigrum (peppercorn)" src="https://images.theconversation.com/files/559177/original/file-20231113-23-f91rga.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/559177/original/file-20231113-23-f91rga.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/559177/original/file-20231113-23-f91rga.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/559177/original/file-20231113-23-f91rga.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/559177/original/file-20231113-23-f91rga.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/559177/original/file-20231113-23-f91rga.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/559177/original/file-20231113-23-f91rga.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"><em>Piper nigrum</em> is also called black pepper.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pepper-piper-nigrum-peppercorn-common-1158781747">Shutterstock</a></span>
</figcaption>
</figure>
<p><em>Piper nigrum</em> is often added to curcumin products to improve the absorption of curcumin, as is the case with the PanaNatra Joint Pain product.</p>
<p>For musculoskeletal pain, a <a href="https://pubmed.ncbi.nlm.nih.gov/32664057/">preliminary human trial</a> that examined the effects of a 1,000 mg daily dose of Rhuleave K (the extract used in PanaNatra) found it was as effective as paracetamol. </p>
<p>But the study was not placebo-controlled and the dose of paracetamol given (1,000 mg per day) was below the recommended daily intake for pain relief.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/knee-pain-heres-why-it-happens-and-how-you-can-fix-it-211858">Knee pain: here’s why it happens and how you can fix it</a>
</strong>
</em>
</p>
<hr>
<p><strong><em>Withania somnifera</em></strong></p>
<p><em>Withania somnifera</em> (also called Ashwagandha) has been used in <a href="https://medlineplus.gov/druginfo/natural/953.html">traditional Indian Ayurvedic medicine</a> for thousands of years to reduce stress and ease inflammation. </p>
<figure class="align-center ">
<img alt="Withania somnifera plant, commonly known as Ashwagandha (winter cherry)" src="https://images.theconversation.com/files/559178/original/file-20231113-21-zdguhr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/559178/original/file-20231113-21-zdguhr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/559178/original/file-20231113-21-zdguhr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/559178/original/file-20231113-21-zdguhr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/559178/original/file-20231113-21-zdguhr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/559178/original/file-20231113-21-zdguhr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/559178/original/file-20231113-21-zdguhr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ashwagandha, or <em>Withania somnifera</em>, is sometimes called winter cherry.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/withania-somnifera-plant-commonly-known-ashwagandha-2237392831">Shutterstock</a></span>
</figcaption>
</figure>
<p>One of the key chemicals appears to be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8705790/">withaferin A</a> which interferes with the inflammatory signalling pathway. </p>
<p>PanaNatra’s Pain and Sleep product contains 300 mg per tablet of a <em>Withania somnifera</em> extract called KSM66.</p>
<p>A <a href="https://pubmed.ncbi.nlm.nih.gov/32818573/">human trial</a> found a daily 600 mg dose of <em>Withania somnifera</em> extract improved sleep quality and helped in managing insomnia.</p>
<p><a href="https://assets.cureus.com/uploads/original_article/pdf/25730/1612429507-1612429503-20210204-18590-tdgx00.pdf">In a separate trial</a>, <em>Withania somnifera</em> was found to improve sleep quality, again when administered at a dose of 600 mg per day.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-ayurveda-to-biomedicine-understanding-the-human-body-85631">From Ayurveda to biomedicine: understanding the human body</a>
</strong>
</em>
</p>
<hr>
<h2>So what does this mean?</h2>
<p>Whether, and how well, a herbal medicine works is largely dependent on the formulation (how it’s made and the extract used) and the dose provided. The same herb used in one formulation may result in a different outcome than a different formulation containing the same herb. </p>
<p>It’s also important to note that effectiveness for one type of pain does not mean a product will work for other types of pain. </p>
<p>Overall, similar herb extracts to those that have been included in the PanaNatra products do have some evidence that they work for pain and sleep. Whether they work for you will depend on a number of factors including the effectiveness of the PanaNatra formulation, how much you take, and the extent of your pain.</p>
<h2>Are they safe?</h2>
<p>PanaNatra needs to be used carefully by some patients. </p>
<p>Overall, there is insufficient human data to recommend any of these herbal ingredients in pregnancy or lactation. In fact there is some evidence that <em><a href="https://www.sciencedirect.com/science/article/pii/S2210803321000142">Withania somnifera</a></em> may be unsafe to use in pregnancy, and other than the amounts commonly found in food, turmeric and its compounds are <a href="https://www.nccih.nih.gov/health/turmeric">not considered safe</a> to use in pregnancy either. </p>
<p>The herbs may also impact the effectiveness and safety of other medicines. For example, the blood levels of the cancer drug <a href="https://link.springer.com/article/10.1007/s00280-023-04504-z">tamoxifen may be reduced</a> when taken concurrently with turmeric supplements. </p>
<p><em>Withania somnifera</em> has been associated with drowsiness and cases of <a href="https://www.mdpi.com/1660-4601/20/5/3921">liver toxicity</a>.</p>
<p><em>Curcuma longa</em> products, including formulations containing curcumin and piperine, have also been associated with liver toxicity. As such, Australia’s Therapeutic Goods Administration has proposed <a href="https://consultations.tga.gov.au/medicines-regulation-division/low-neg-risk-2023-2024/user_uploads/tga---low-negligible-risk-annual-consultation-2023-2024---final.pdf">adding warning labels</a> to any products that contain those ingredients. But this discussion is ongoing and a decision won’t be made until next year. </p>
<h2>Bottom line</h2>
<p>While there is a long history of traditional use of the herbs in the PanaNatra products, there is limited high-quality scientific evidence for the effectiveness and safety for these specific products. </p>
<p>Pregnant and breastfeeding women should not take these products, and you should not exceed the daily dose recommended by the manufacturer. </p>
<p>If you have an underlying health condition, or are taking other medication, before you try them, consult your doctor or pharmacist to check if these products are suitable for you.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-you-know-whats-in-the-herbal-medicine-youre-taking-72726">Do you know what's in the herbal medicine you're taking?</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/216445/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nial Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is a Fellow of the Royal Australian Chemical Institute, a member of the Australasian Pharmaceutical Science Association, and a member of the Australian Institute of Company Directors. Nial is the chief scientific officer of Vaihea Skincare LLC, a director of SetDose Pty Ltd a medical device company, and a Standards Australia panel member for sunscreen agents. Nial regularly consults to industry on issues to do with medicine risk assessments, manufacturing, design, and testing.</span></em></p><p class="fine-print"><em><span>Joanna Harnett is an academic University of Sydney’s Faculty of Medicine and Health Pharmacy School where she teaches and conducts research in the field of traditional, complementary, and integrative medicine (TCIM). She has received research funds from universities, organisations, and/or industry for TCIM research and education and received payments for providing expert advice about TCIM to industry, government bodies and/or non-government organisations, and/or spoken at workshops, seminars and/or conferences for which registration, travel and/or accommodation has been paid for by the organisers.
The institutes, centres and universities associated with the authors receive research grants, donations and endowments from foundations, universities, government agencies, individuals, and industry. Sponsors and donors have provided untied funding to advance TCIM education and research. This viewpoint article was not undertaken as part of a contractual relationship with any donor or sponsor.
</span></em></p>PanaNatra is a line of herbal products from the makers of Panadol. But can herbal ingredients relieve different types of pain?Nial Wheate, Associate Professor of the School of Pharmacy, University of SydneyJoanna Harnett, Lecturer (Complementary Medicines) Sydney Pharmacy School, Faculty of Medicine and Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2142102023-11-03T12:43:40Z2023-11-03T12:43:40ZUnderstanding that chronic back pain originates from within the brain could lead to quicker recovery, a new study finds<figure><img src="https://images.theconversation.com/files/551241/original/file-20230929-27-cur5dq.jpg?ixlib=rb-1.1.0&rect=56%2C0%2C6240%2C4100&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Approximately 16 million U.S. adults have chronic back pain.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/suffering-man-holding-his-back-in-spring-park-royalty-free-image/1490418520?phrase=lower+back+pain&adppopup=true">Olena Ruban/Moment via Getty Images</a></span></figcaption></figure><p>Most people with chronic back pain naturally think their pain is caused by injuries or other problems in the body such as arthritis or bulging disks. But our research team has found that thinking about the root cause of pain as a process that’s occurring in the brain can help promote recovery. That is a key finding of a study my colleagues and I <a href="https://doi.org/10.1001/jamanetworkopen.2023.33846">recently published in JAMA Network Open</a>, a monthly open-access medical journal.</p>
<p>We have been studying a psychological treatment called <a href="https://www.physio-pedia.com/Pain_Reprocessing_Therapy">pain reprocessing therapy</a> that may help “turn off” unhelpful and unnecessary pain signals in the brain. To do this, we carried out a study in which some people were randomly chosen to receive the pain reprocessing therapy treatment, while some got a placebo injection into their backs.</p>
<p>We included 151 adults ages 21 to 70 years old with chronic back pain. We found that 66% of participants reported being pain-free or nearly pain-free after pain reprocessing therapy, compared with 20% of people who received a placebo. </p>
<p>These results were remarkable because previous trials of psychological treatments <a href="https://doi.org/10.1097/j.pain.0000000000002357">rarely led to people reporting full recoveries</a> from chronic pain. So we needed to better understand how this treatment worked: What changed in people’s thinking that helped them recover from chronic back pain? </p>
<h2>Why it matters</h2>
<p>Chronic pain is one of the <a href="https://doi.org/10.15585/mmwr.mm6736a2">biggest health problems today</a>. It is the leading cause of disability in the U.S., and it has <a href="https://doi.org/10.17226/13172">an economic cost greater than that of diabetes or cancer</a>. </p>
<p>The most common chronic pain condition is <a href="https://www.ncbi.nlm.nih.gov/books/NBK538173/">back pain</a>. Many patients – and doctors – are focused on identifying different back problems that they suspect may be causing the pain. So they try all sorts of treatments, <a href="https://doi.org/10.1016/S2665-9913(21)00032-1">often to no avail</a>. </p>
<p>A growing number of scientists now believe that many cases of chronic back pain are <a href="https://doi.org/10.1016/s0140-6736(21)00392-5">caused primarily by brain changes</a>. Pain can originate with an injury, but then the pain system can get “stuck” and keep firing <a href="https://doi.org/10.1093%2Fbrain%2Fawt211">long after injuries have healed</a>. </p>
<p>Pain is the brain’s alarm system, letting us know about injuries or other threats to our body. Much of the time, the system works well, accurately warning us that a part of our body is injured and needs to be protected. But when a person has been in pain for months, years or even decades, pain processing pathways are more likely to fire, and brain regions that typically are not involved in pain start to be involved. Chronic pain also leads to <a href="https://doi.org/10.1038/nri3621">increased levels of activity in glial cells</a>, which are part of the brain’s immune system. All these changes in the brain then serve to “entrench” the pain, making it persist.</p>
<p>People, very understandably, think that if their back hurts, there must be a problem in the back – even though we researchers <a href="https://doi.org/10.3174/ajnr.A4173">know this is often not the case</a>. </p>
<p>It’s critical to note that just because the signal originates in the brain, the pain is not any less real. The pain is always real, no matter what. But to treat it effectively, one needs to accurately identify the root cause. </p>
<h2>How we do our work</h2>
<p>In our study, we asked people to tell us in their own words what they think is the cause of their chronic back pain. It is a simple question, but few studies have asked their participants to describe the source of their pain.</p>
<p>Participants in our study described injuries, weak muscles, arthritis and other bodily factors as the causes of their pain. Almost no one mentioned anything about the mind or brain. </p>
<p>One of the main goals of pain reprocessing therapy is to help people think differently about the causes of their pain. After we treated participants with pain reprocessing therapy, about half the causes of pain that people described were related to the mind or brain. They said things like “anxiety,” “fear” or “neural pathways” were the causes of their pain. </p>
<p>The more that people shifted to this kind of understanding, the more their back pain went down. We think this shift in understanding reduces fear and avoidance of pain, which can tamp down pain pathways in the brain and promote healthy, pain-reducing behaviors like exercise and socializing.</p>
<p>Ask your health providers, or check out <a href="https://centerforinsightmedicine.com/nsq-explanations/">these online resources</a> that can <a href="https://ppdassociation.org/ppd-self-questionnaire">help you assess</a> whether and when the brain is playing a role in chronic pain. </p>
<p>Accurately identifying the underlying causes of pain is the first step toward healing it.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take on interesting academic work.</em></p><img src="https://counter.theconversation.com/content/214210/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yoni Ashar consults for Lin Health, Inc., the Pain Reprocessing Therapy Center, and Mental Health Partners of Boulder County. He receives funding from the NIH, VA, and the Psychophysiological Disorders Assocation. </span></em></p>An intriguing therapy that shifts what people perceive as the source of their pain could aid in pain management.Yoni Ashar, Assistant Professor of General Internal Medicine, University of Colorado Anschutz Medical CampusLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2158702023-10-27T12:18:30Z2023-10-27T12:18:30ZWhite patients are more likely than Black patients to be given opioid medication for pain in US emergency departments<figure><img src="https://images.theconversation.com/files/556165/original/file-20231026-19-8q0th6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5499%2C3663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors have struggled to find the balance between effective pain management and the very real addiction risks that come with prescription pain medication.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/macro-of-oxycodone-opioid-tablets-with-prescription-royalty-free-image/1162845770?phrase=pain+treatment&adppopup=true">BackyardProduction/iStock via Getty Images Plus</a></span></figcaption></figure><p>White people who visit hospital emergency departments with pain are 26% more likely than Black people to be given opioid pain medications such as morphine. This was a key finding from <a href="https://doi.org/10.1007/s11606-023-08401-2">our recent study</a>, published in the Journal of General Internal Medicine. We also found that Black patients were 25% more likely than white patients to be given only non-opioid painkillers such as ibuprofen, which are typically available over the counter. </p>
<p>We examined more than 200,000 visit records of patients treated for pain, taken from a representative sample of U.S. emergency departments from 1999 to 2020. Although white patients were far more likely to be prescribed opioid medication for their pain, we found no significant differences across race in either the type or severity of patients’ pain. Furthermore, racial disparities in pain medication remained even after we adjusted for any differences in insurance status, patient age, census region or other potentially important factors.</p>
<p>Our analysis of prescribing trends spanning over two decades’ worth of records found that opioid prescribing rates rose and fell, reflecting changing attitudes in clinical practice toward the use of opioid drugs. Notably, however, there appeared to be little change over time in the prescribing disparity across race.</p>
<p><iframe id="G0M5M" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/G0M5M/1/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Why it matters</h2>
<p>These findings are important because they suggest that efforts to promote equitable health care in the U.S. over the past two decades, such as <a href="https://www.hhs.gov/healthcare/about-the-aca/index.html">the Affordable Care Act</a>, or “Obamacare,” do not appear to have translated to clinical practice – at least with regards to pain management in hospital emergency departments.</p>
<p>There’s no question that as the <a href="https://www.nytimes.com/2023/02/20/nyregion/sudden-deaths-overdoses-fentanyl-nyc.html">ongoing opioid crisis</a> <a href="https://www.npr.org/2023/08/30/1196343448/fentanyl-deaths-teens-schools-overdose">continues to escalate</a>, a careful balance must be struck between the risks and benefits of prescribing opioids. But their appropriate use is an essential component of pain control in the emergency department, and they typically provide superior relief to non-opioids for short-term moderate to severe pain. </p>
<p>Undertreated pain produces unnecessary suffering and can result in a range of negative outcomes, even including a <a href="https://doi.org/10.1111/j.1526-4637.2010.00983.x">greater likelihood of developing long-term pain</a>. There are over <a href="https://doi.org/10.1007/s11606-023-08401-2">40 million pain-related emergency department visits annually</a>, so it is clear that equitable pain treatment is a fundamental component of a fair health care system. </p>
<h2>What still isn’t known</h2>
<p>We do not know why such marked racial disparities exist. Some researchers <a href="https://doi.org/10.1056%2FNEJMsa2034159">have argued</a> that prescribing fewer opioids may be beneficial for Black patients as it reduces the risk of addiction. But this argument doesn’t square with the data, which show that overdose rates have traditionally been <a href="https://doi.org/10.1111/add.15233">lower in Black populations compared with white people</a>. However, this trend has <a href="https://doi.org/10.1111/add.15233">started to change in recent years</a>. </p>
<p>In addition, some evidence suggests that clinicians <a href="https://doi.org/10.1073/pnas.1516047113">may hold unconscious biases</a>, incorrectly believing Black patients to be less sensitive to pain or that certain racial groups are <a href="https://doi.org/10.1371/journal.pmed.1001411">less willing to accept pain medication</a>. </p>
<p>While there is preliminary evidence that these factors may be important, there is not enough research that examines the degree to which they influence clinical practice. Researchers like us also know very little about whether promising remedial strategies based on these factors – such as educational training during medical school that challenges stereotypical beliefs – are effective, or indeed even implemented, in the real world. </p>
<h2>What’s next?</h2>
<p>The need for tackling racial disparities in health was brought into focus once more in February 2023, when the <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/02/16/fact-sheet-president-biden-signs-executive-order-to-strengthen-racial-equity-and-support-for-underserved-communities-across-the-federal-government/">Biden-Harris administration</a> signed an executive order on further advancing racial equity. Given the long history of these issues, it is clear that more research is needed to help develop better strategies for tackling health inequalities.</p>
<p>The most effective strategies for addressing racial disparities in pain treatment are likely to be those that target the underlying causes. We are currently undertaking research to try to better understand these causes, how they contribute to disparities in real-world clinical practice and whether strategies designed to address them are actually effective.</p><img src="https://counter.theconversation.com/content/215870/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Undertreated pain can result in unnecessary suffering and a greater likelihood of long-term chronic pain.Trevor Thompson, Associate Professor of Clinical Research, University of GreenwichSofia Stathi, Professor of Social Psychology, University of GreenwichLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2074622023-09-18T12:18:39Z2023-09-18T12:18:39ZWhat ancient Greek stories of humans transformed into plants can teach us about fragility and resilience<figure><img src="https://images.theconversation.com/files/543533/original/file-20230818-28315-o2b0v4.jpg?ixlib=rb-1.1.0&rect=3%2C9%2C2041%2C1342&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Stories from Greek mythology often show the close relationship between humans and plants.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/kristoffer-trolle/17306790922">Kristoffer Trolle/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>For me, gardening is the most joyful summer activity, when I can see my hard work rewarded with colorful blooms and lush greenery. Science explains this feeling by recognizing <a href="https://theconversation.com/how-the-relationships-we-have-with-plants-contribute-to-human-health-in-many-ways-169817">the deep bond</a> between humans and plants. Being in a nurturing relationship with nature supports our <a href="https://doi.org/10.7861/clinmedicine.18-3-201">physical and mental health</a>. </p>
<p>At the same time, <a href="https://as.tufts.edu/classicalstudies/people/faculty/marie-claire-beaulieu">as a scholar of Greek mythology</a>, I also see the close relationship between humans and plants reflected in ancient stories. In fact, Greek literature and poetry often represent human life as plant life. </p>
<p>Just like plant life, human life follows the course of the seasons. Our youth is brief and beautiful like the spring, followed by the full bloom of adulthood in summer and the maturity of middle age, which yields bounty and prosperity like the fall harvest. Finally, in the winter of our life, we wither and die, to be replaced by a new generation, as famously described in the <a href="https://www.poetryintranslation.com/PITBR/Greek/Iliad6.php#anchor_Toc239244954">Greek epic “The Iliad</a>”: “Like the generations of leaves are those of men. The wind blows and one year’s leaves are scattered on the ground, but the trees bud and fresh leaves open when spring comes again.”</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/543527/original/file-20230818-23-xa3uq9.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A photograph showing yellow and purple flowers outside a church building." src="https://images.theconversation.com/files/543527/original/file-20230818-23-xa3uq9.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543527/original/file-20230818-23-xa3uq9.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543527/original/file-20230818-23-xa3uq9.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543527/original/file-20230818-23-xa3uq9.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543527/original/file-20230818-23-xa3uq9.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543527/original/file-20230818-23-xa3uq9.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543527/original/file-20230818-23-xa3uq9.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Daffodils and hyacinths at Whitwell Church of St Mary and St Radegund in the U.K.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Daffodils_and_hyacinths_at_Whitwell_Church_of_St_Mary_and_St_Radegund.JPG">Editor5807 via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>In this way, Greek mythology spells out that human life, with its beauty and its sufferings, is part of the broader cycle of nature and should be viewed on par with other living creatures, such as plants.</p>
<h2>Unlucky youth</h2>
<p>Spring flowers are brightly colored, but they only last a short time, so they reminded the Greeks of the beauty and promise of youth and the tragedy of young lives cut short.</p>
<p>For instance, Greek myths tell the story of Narcissus, a young hunter who was so beautiful that he fell in love with his own image reflected in a pool. He couldn’t tear himself away, so he eventually withered on that spot and gave his name to a <a href="http://www.perseus.tufts.edu/hopper/text?doc=urn:cts:latinLit:phi0959.phi006.perseus-eng1:3.435-3.508">pale white and yellow flower</a>, the narcissus, which is called daffodil in English. </p>
<p>Similarly, after the beautiful Adonis, beloved of the goddess Aphrodite, <a href="http://www.perseus.tufts.edu/hopper/text?doc=urn:cts:latinLit:phi0959.phi006.perseus-eng1:10.652">died in a boar hunting accident</a>, the goddess turned his blood into the red anemone flower, the “wind-flower” – <em>Anemone coronoria</em> – named for its fragile stem tossed in the wind.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/543531/original/file-20230818-21-1x6wlk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A fresco showing the back of a young woman, with head slightly turned, wearing a gown with shades of yellow." src="https://images.theconversation.com/files/543531/original/file-20230818-21-1x6wlk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543531/original/file-20230818-21-1x6wlk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=796&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543531/original/file-20230818-21-1x6wlk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=796&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543531/original/file-20230818-21-1x6wlk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=796&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543531/original/file-20230818-21-1x6wlk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1000&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543531/original/file-20230818-21-1x6wlk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1000&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543531/original/file-20230818-21-1x6wlk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1000&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Roman goddess Flora depicted on a fresco in the Villa di Arianna in Stabiae near Pompeii, first century C.E.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Flora,_fresco_Villa_of_Ariadne_in_Stabiae_near_Pompei,_c._15-45_AD_(38594045730).jpg">ArchaiOptix via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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</figure>
<p>The hyacinth recalls the beautiful boy Hyacinthus, who was killed while he trained with the discus. His lover, the god Apollo, grew a flower on the spot and <a href="http://www.perseus.tufts.edu/hopper/text?doc=urn:cts:latinLit:phi0959.phi006.perseus-eng1:10.143-10.219">inscribed the letters AI on it</a>, representing the Greek exclamation for grief “Ia! Ia!” Other authors say it represents <a href="https://topostext.org/work/808#46">the beginning of Hyacinthus’ name in Greek</a> – Ὑάκινθος. </p>
<p>Scholars believe that this flower is not the hyacinth commonly grown in our gardens – <em>Hyacinthus orientalis</em>. The exact species of the flower, however, <a href="https://books.google.com/books/about/Narcisse_ou_Le_sang_des_fleurs.html?id=ymhxMAEACAAJ">is still debated</a> because it is difficult to find a flower that looks like it has letters on it, as the ancient descriptions assert.</p>
<p>The beauty of young women was also associated with ephemeral spring flowers. <a href="http://www.perseus.tufts.edu/hopper/text?doc=urn:cts:greekLit:tlg0013.tlg006.perseus-eng1:6">Violets</a> and <a href="https://www.poetryintranslation.com/PITBR/Greek/Sappho.php#anchor_Toc76357043">roses</a> appear with Aphrodite, the goddess of love, <a href="https://chs.harvard.edu/read/brockliss-william-homeric-imagery-and-the-natural-environment/">and in love poetry</a>. The ancient rose, unlike our modern heavily hybridized cultivars, <a href="https://muse.jhu.edu/pub/77/article/591290/pdf">only bloomed briefly in the spring</a> and thus was a fitting image for the fleeting beauty of youth. </p>
<figure class="align-right ">
<img alt="A photograph of an open bright pink flower showing its pollen producing parts." src="https://images.theconversation.com/files/543529/original/file-20230818-19-6qkvqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543529/original/file-20230818-19-6qkvqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=549&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543529/original/file-20230818-19-6qkvqf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=549&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543529/original/file-20230818-19-6qkvqf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=549&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543529/original/file-20230818-19-6qkvqf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=690&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543529/original/file-20230818-19-6qkvqf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=690&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543529/original/file-20230818-19-6qkvqf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=690&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Rosa Gallica, one of the ancient species from which modern roses are descended.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Wild_Rosa_gallica_Romania.jpg#filelinks">Via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<h2>Picking flowers</h2>
<p>Because flowers are associated with beauty and attractiveness, picking flowers in Greek mythology evokes a young woman’s discovery of sexuality. For instance, the beautiful Europa, a princess from the Eastern Mediterranean, <a href="http://www.perseus.tufts.edu/hopper/text?doc=urn:cts:latinLit:phi0893.phi001.perseus-eng1:3.27">was picking flowers</a> when she was abducted by the god Zeus and transported across the sea to the island of Crete, where she gave birth to the mythical king Minos.</p>
<p>As classical scholar <a href="https://www.philo.uliege.be/cms/c_7668233/fr/andre-motte-en-memoire">André Motte</a> demonstrated, the discovery of sexuality was frequently <a href="https://www.academieroyale.be/Academie/documents/LXI5_Motte_Prairiesetjardins_197312905.pdf">formulated in terms of death</a>, and flowery meadows were imagined to be a portal to the underworld. For instance, the beautiful young Persephone, daughter of Demeter, <a href="http://www.perseus.tufts.edu/hopper/text?doc=urn:cts:greekLit:tlg0013.tlg002.perseus-eng1:2">was picking a bouquet</a> of lilies, narcissus and violets when she was abducted by Hades, the god of death.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/543525/original/file-20230818-29-afeqow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A rectangular stone shaft showing a standing young man." src="https://images.theconversation.com/files/543525/original/file-20230818-29-afeqow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543525/original/file-20230818-29-afeqow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=2690&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543525/original/file-20230818-29-afeqow.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=2690&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543525/original/file-20230818-29-afeqow.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=2690&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543525/original/file-20230818-29-afeqow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=3380&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543525/original/file-20230818-29-afeqow.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=3380&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543525/original/file-20230818-29-afeqow.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=3380&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Funerary monument of a young Greek athlete holding pomegranates, 550 B.C.E.</span>
<span class="attribution"><a class="source" href="https://collections.mfa.org/objects/151018/funerary-monument-for-an-athlete;jsessionid=968FC7359972332A8CA64DE7D2275133">Museum of Fine Arts, Boston</a></span>
</figcaption>
</figure>
<h2>The symbolism of fruit</h2>
<p>While spring flowers represented sexual attraction, the fruit that comes in the summer and fall, to the Greeks, represented the consummation of sexuality. Thus, once Persephone was in the underworld, she accepted a pomegranate from Hades, which sealed her fate <a href="https://topostext.org/work/355#370">to remain in the underworld</a> for a part of each year. </p>
<p>The pomegranate, whose bright red juice recalls blood, was often seen as a symbol of sexuality as well as early death in Greek art. Indeed, Persephone is symbolically dead while in the underworld, and her absence brings about winter on Earth.</p>
<p>Similar to pomegranates, apples are common as <a href="https://www.poetryintranslation.com/PITBR/Latin/PropertiusBkOne.php#anchor_Toc201112142">lover’s gifts</a> and represent female fertility. Gaia, the Earth goddess, created the apple tree <a href="https://topostext.org/work/207/#2.3.1">for Hera’s wedding</a>, emphasizing the beauty and fertility of this divine bride, the goddess of marriage and queen of the Greek pantheon. </p>
<h2>The bleakness of winter</h2>
<p>After the fruit of the harvest has been consumed and the fall has turned to winter, both plants and humans wither and die. </p>
<p>The Greeks imagined that plants were colorless in the underworld because white was the color of ghosts. The <a href="https://topostext.org/work/3#OD.24.10">dead lived in meadows of asphodel</a>, a grayish-white flower, and pale willows and white poplars also grew there. The god Hades created the white poplar in memory of the nymph Leuke, “the White One,” whom he loved before her untimely death. </p>
<figure class="align-right ">
<img alt="A circular walled ancient monument with cyprus trees around it." src="https://images.theconversation.com/files/543522/original/file-20230818-27-6n0dv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543522/original/file-20230818-27-6n0dv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543522/original/file-20230818-27-6n0dv3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543522/original/file-20230818-27-6n0dv3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543522/original/file-20230818-27-6n0dv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543522/original/file-20230818-27-6n0dv3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543522/original/file-20230818-27-6n0dv3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Mausoleum of Augustus in Rome.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/184393744@N06/49345593857/">Jamie Heath via Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span>
</figcaption>
</figure>
<p>In contrast, the dark cypress also represented the dead and was commonly grown on funerary monuments. The tree was named after Cyparissus, a boy who inadvertently killed his pet deer and mourned unceasingly, so much so that he was transformed <a href="https://topostext.org/work/141#10.126">into the tree that symbolized mourning</a>.</p>
<p>However, some plants survive the winter and keep their green color, such as the laurel, myrtle and ivy, which were common in <a href="https://www.bloomsbury.com/us/cultural-history-of-gardens-in-antiquity-9781350009868/">ancient Greek and Roman gardens</a>. The ivy offered hope during the dreary season because it was sacred to Dionysus, <a href="https://doi.org/10.7591/9781501733680-017">a god of joy, wine and freedom who had returned from the dead</a>. Ivy represented Dionysus’ power to spread happiness and the ability to free people from the bonds of everyday experiences.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/543526/original/file-20230818-28498-ftuy32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A rust colored cup with drawings of ivy, vines and dolphins." src="https://images.theconversation.com/files/543526/original/file-20230818-28498-ftuy32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/543526/original/file-20230818-28498-ftuy32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=567&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543526/original/file-20230818-28498-ftuy32.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=567&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543526/original/file-20230818-28498-ftuy32.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=567&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543526/original/file-20230818-28498-ftuy32.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=713&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543526/original/file-20230818-28498-ftuy32.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=713&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543526/original/file-20230818-28498-ftuy32.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=713&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Wine cup showing Dionysus on a boat, from 540–530 B.C.E.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Exekias_Dionysos_Staatliche_Antikensammlungen_2044_n2.jpg">Collection Staatliche Antikensammlungen via Wikimedia Commons</a></span>
</figcaption>
</figure>
<p>Today, ivy is still seen as a symbol of <a href="https://www.nrscotland.gov.uk/research/archivists-garden/index-by-plant-name/rock-ivy">eternal life and everlasting loyalty</a>, and is featured both on funerary monuments and in bridal bouquets.</p>
<h2>Pain and transformation</h2>
<p>Why did the natural beauty of the plant world, for the Greeks, evoke so many sad stories? </p>
<p>As noted by classical scholar <a href="https://as.nyu.edu/faculty/alessandro-barchiesi.html">Alessandro Barchiesi</a>, “Nature is <a href="https://doi.org/10.1093/oso/9780198864066.003.0002">in perennial flux</a>, everything transforms, but metamorphosis tends to produce a new ‘state of nature’ that no longer changes.”</p>
<p>By acquiring a new form through metamorphosis, the people in these stories attain a stable life that resolves the misfortunes they have gone through. For instance, Cyparissus, mourning for his deer, finds a reprieve from his grief by becoming a cypress. At the same time, his story is not forgotten since it is memorialized in the very name of the cypress and its significance as a tree of mourning.</p>
<p>In this way, metamorphosis <a href="https://hdl.handle.net/10520/EJC100204">offers relief from painful experiences</a> by integrating the sufferer into the eternal and stable cycle of nature, while commemorating the transformation through stories. </p>
<p>Greek mythology suggests that human sufferings, though painful, eventually come to an end because they are part of the broader and everlasting cycle of nature. Still today, these stories teach us to view our own grief and the painful experiences we go through in the broader context of the ever-changing, yet cyclical, natural world. </p>
<p>In this way, like the people in the Greek stories who are transformed into plants by intense grief, we too can find consolation in learning that grief itself changes over time, and most importantly, it changes <a href="https://www.apa.org/news/podcasts/speaking-of-psychology/grieving-changes-brain">who we are as people</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/543532/original/file-20230818-48215-h4mqsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A fresco showing a garden scene with fruits, flowers and birds against the backdrop of a blue sky" src="https://images.theconversation.com/files/543532/original/file-20230818-48215-h4mqsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543532/original/file-20230818-48215-h4mqsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543532/original/file-20230818-48215-h4mqsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543532/original/file-20230818-48215-h4mqsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543532/original/file-20230818-48215-h4mqsp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543532/original/file-20230818-48215-h4mqsp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543532/original/file-20230818-48215-h4mqsp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Roman fresco in the Villa of Livia, Palazzo Massimo alle Terme, Rome.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Fresque_du_nymph%C3%A9e_souterrain_de_la_villa_Livia_-_Mus%C3%A9e_national_romain_-_mur_nord-est_-_4.jpg">Shonagon via Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure><img src="https://counter.theconversation.com/content/207462/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marie-Claire Beaulieu does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Stories in Greek mythology on the cycle of nature showing youth, death and rejuvenation can have lessons for us today on how grief changes over time and transforms who we are as people.Marie-Claire Beaulieu, Associate Professor of Classical Studies, Tufts UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2078662023-09-12T11:38:21Z2023-09-12T11:38:21ZWomen’s pain is often not believed – here’s how to make your voice heard when seeking help<figure><img src="https://images.theconversation.com/files/545961/original/file-20230901-29-5qos98.jpg?ixlib=rb-1.1.0&rect=6%2C0%2C4287%2C3495&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One survey found over half of female respondents had had their pain dismissed by a clinician.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/menstrual-pain-sad-arab-woman-hijab-2088577228">Keronn art/ Shutterstock</a></span></figcaption></figure><p>When you go to the doctor, you expect they’ll listen to your concerns and help fix whatever problem you may be experiencing. But <a href="https://theconversation.com/womens-pain-is-routinely-underestimated-and-gender-stereotypes-are-to-blame-new-research-158599">many women</a>, especially those suffering with chronic pain conditions, find the opposite is true. This can make it difficult for women to get the treatment they need.</p>
<p>For instance, researchers who interviewed endometriosis sufferers on their experiences with healthcare practitioners found many struggled to <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1111/jocn.13872?casa_token=Mp6VZw4Y2fgAAAAA:xndGnnnaNPs9nsEP4xCVPZ6WviGsxp5BWEhgiuy3TZpnA8rDIdLDuugfO2zh6LeGTPpTqKHJ__0WNQE">get the support</a> they needed. As one participant put it, “you need to try so hard that they believe you, because they don’t. You experience that immediately, that they don’t believe you.”</p>
<p>In the UK, a survey by the Wellbeing of Women charity (which invests in research on women’s health) found that over <a href="https://www.wellbeingofwomen.org.uk/news/over-half-of-uk-women-feel-their-pain-is-ignored-or-dismissed-new-report-shows">half of female respondents</a> felt their pain had been dismissed or ignored by a healthcare professional at some point. Women in other parts of the world – including North America, Australia and <a href="https://journals.sagepub.com/doi/full/10.1177/1403494820987466">Europe</a> – report <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845507/">similar experiences</a>. </p>
<p>There’s a clear <a href="https://journals.sagepub.com/doi/full/10.1177/1403494820987466">gender gap</a> when it comes to identifying and treating women’s pain compared to men’s. For instance, women are less likely than men to <a href="https://pubmed.ncbi.nlm.nih.gov/29682130/">have positive treatment outcomes</a> for chronic conditions such as angina and musculoskeletal pain.</p>
<p>Physicians are <a href="https://pubmed.ncbi.nlm.nih.gov/18332383/">four times more likely</a> to recommend a knee replacement for a man than a woman with the same knee injury. The poorer quality care women received compared to men after suffering a heart attack was to blame for <a href="https://heart.bmj.com/content/105/7/516">8,243 preventable deaths</a> between 2003-2013 in England and Wales.</p>
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<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/542294/original/file-20230811-4652-hn8w80.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em>This article is part of <a href="https://theconversation.com/uk/topics/womens-health-matters-143335">Women’s Health Matters</a>, a series about the health and wellbeing of women and girls around the world. From menopause to miscarriage, pleasure to pain the articles in this series will delve into the full spectrum of women’s health issues to provide valuable information, insights and resources for women of all ages.</em></p>
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<p><em><a href="https://theconversation.com/science-experiments-traditionally-only-used-male-mice-heres-why-thats-a-problem-for-womens-health-205963">Science experiments traditionally only used male mice – here’s why that’s a problem for women’s health</a></em></p>
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<p>The dismissal of women’s pain also leads to long delays in diagnoses and treatment for conditions such as <a href="https://theconversation.com/people-with-endometriosis-and-pcos-wait-years-for-a-diagnosis-attitudes-to-womens-pain-may-be-to-blame-179500">polycystic ovary syndrome (PCOS)</a> and <a href="https://theconversation.com/endometriosis-three-reasons-care-still-hasnt-improved-157457">endometriosis</a>. </p>
<p>The gender pain gap affects not only adults, but <a href="https://academic.oup.com/jpepsy/article/44/4/403/5273626?login=false">children</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/29110522/">young people</a> – with research showing young women are more likely to have their <a href="https://pubmed.ncbi.nlm.nih.gov/29110522/">pain dismissed</a> by physicians than young men.</p>
<p>The gender pain gap is even worse for <a href="https://theconversation.com/endometriosis-black-women-continue-to-receive-poorer-care-for-the-condition-200663#:%7E:text=In%20the%20US%2C%20almost%2072,more%20common%20in%20white%20patients.">black women</a>, who are more likely than white women to have their pain dismissed and receive <a href="https://www.pnas.org/doi/full/10.1073/pnas.1516047113">poorer pain treatment</a>.</p>
<p>There also remains <a href="https://www.frontiersin.org/research-topics/25413/pain-in-the-transgender-individual">little research</a> on pain treatment for gender diverse, transgender, non-binary and intersex patients which may mean these groups are even worse off when accessing treatment.</p>
<h2>Gender pain gap</h2>
<p>Pervasive <a href="https://theconversation.com/womens-pain-is-routinely-underestimated-and-gender-stereotypes-are-to-blame-new-research-158599">gender stereotypes</a> are a key reason women’s pain is underestimated. These widely held stereotypes – held even by <a href="https://www.jpain.org/article/S1526-5900(21)00035-3/fulltext">healthcare professionals</a> – construct men as “stoic” and women as “<a href="https://philpapers.org/rec/BENPAG">emotionally expressive</a>” when in pain. </p>
<p>Men are thought to be less likely to seek care for pain – so when they do, they are to be believed. In actuality, this is false, with <a href="https://pubmed.ncbi.nlm.nih.gov/10387413/">research showing</a> men are equally likely to go to the doctor when <a href="https://pubmed.ncbi.nlm.nih.gov/10387413/">experiencing pain</a> as women are.</p>
<p>Women are also believed to have a <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=383803">greater capacity to cope</a> with pain because of the pain that accompanies menstruation and childbirth. These stereotypes mean <a href="https://pubmed.ncbi.nlm.nih.gov/33684539/">women’s pain</a> is viewed as “natural” and “normal” – and may not be taken as seriously by a practitioner.</p>
<figure class="align-center ">
<img alt="An older male doctor speaks with a young female patient." src="https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=508&fit=crop&dpr=1 754w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=508&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/545963/original/file-20230901-25-v16yoi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=508&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Even doctors may believe these stereotypes.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/experienced-senior-doctor-modern-clinic-talking-2101295176">Studio Romantic/ Shutterstock</a></span>
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<p>One study, which had healthcare professionals watch videos of female and male patients experiencing chronic shoulder pain, found practitioners were more likely to <a href="https://www.jpain.org/article/S1526-5900(21)00035-3/fulltext">underestimate women’s pain</a>. They also reported the women, but not the men, would benefit from psychotherapy. </p>
<p><a href="https://www.independent.co.uk/life-style/health-and-families/health-news/how-sexist-stereotypes-mean-doctors-ignore-women-s-pain-a7157931.html">Other studies</a> have shown healthcare practitioners are sometimes more likely to prescribe sedatives than pain medication to female patients experiencing pain.</p>
<p><a href="https://www.bmj.com/content/381/bmj.p1303">Historically</a>, women have been underrepresented in medical research and clinical trials. In the UK, only from 2024 will it be compulsory for new GPs to have <a href="https://www.gov.uk/government/news/first-womens-health-strategy-for-england-to-tackle-gender-health-gap">training in women’s health</a>. </p>
<p>This may somewhat explain the lack of knowledge practitioners have had in regards to women’s pain and their health concerns. And, women may be given medications and treatments that have only been trialled with men – despite female patients being more likely to experience <a href="https://www.bmj.com/content/381/bmj.p1303.full">side effects</a> from new medications. </p>
<p>The gender pain gap cannot be addressed until disparities in <a href="https://www.bmj.com/content/381/bmj.p1303.full">medical research and funding</a> are. Conditions which have a disproportional affect on women (such as migraines and endometriosis) receive “<a href="https://www.nature.com/immersive/d41586-023-01475-2/index.html">much less</a>” funding relative to their severity and prevalence, while conditions which predominantly affect men (such as HIV) receive <a href="https://www.nature.com/immersive/d41586-023-01475-2/index.html">more funding</a> – despite their lower prevalence.</p>
<h2>Getting the right care</h2>
<p>Pain is never something you should accept and put up with. If you need to speak with a practitioner about your pain, there are many things you can do to ensure your voice is heard.</p>
<p>For example, telling your practitioner how pain affects your <a href="https://theconversation.com/endometriosis-understanding-how-sufferers-describe-pain-could-lead-to-faster-diagnosis-172073">ability to function</a> in your day-to-day can be more effective than trying to rate pain on a scale. Using an <a href="https://www.healthline.com/health/how-to-advocate-for-pain-management">app or diary to track pain</a> and related symptoms, and bringing it with you in the consultation room, can also be helpful. </p>
<p>If you’re comfortable, raise the <a href="https://www.healthline.com/health/how-to-advocate-for-pain-management#advocate-against-bias">issue of bias in pain care</a>. Ask how your practitioner is ensuring you’re not part of the larger statistic of women feeling dismissed. Ask them to explain their diagnostic decision-making and how they’ve ruled out certain conditions. You can also ask them to note in your file why they haven’t made a referral for specialist care. This may be helpful if you return with the same symptoms later. </p>
<p>Bring a family member or friend to advocate for you if you don’t feel comfortable doing it alone. In the UK, you can also ask for a <a href="https://www.nhs.uk/conditions/social-care-and-support-guide/help-from-social-services-and-charities/someone-to-speak-up-for-you-advocate/">patient advocate</a>, who will speak up for you and help you get the right care.</p>
<p>Addressing <a href="https://www.nihr.ac.uk/blog/improving-womens-health-and-care-through-research/3287">inadequate funding</a> for conditions that affect women, <a href="https://www.elle.com/uk/life-and-culture/culture/a40662488/womens-pain-government-strategy/">improving training</a> for practitioners and <a href="https://www.theguardian.com/see-my-pain/2023/may/26/it-hadnt-all-been-in-my-head-the-truth-about-the-gender-pain-gap#:%7E:text=Despite%20significant%20healthcare%20advances%20in,and%20truly%20alive%20in%202023.">increased awareness</a> of the gender pain gap, will all help ensure women in pain are no longer dismissed.</p><img src="https://counter.theconversation.com/content/207866/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Annalise Weckesser does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Women are less likely than men to have positive treatment outcomes for chronic conditions.Annalise Weckesser, Reader in Medical Anthropology, Birmingham City UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2130432023-09-08T12:24:07Z2023-09-08T12:24:07ZThe beautiful pessimism at the heart of Jimmy Buffett’s music<figure><img src="https://images.theconversation.com/files/547034/original/file-20230907-11065-dq28ko.jpg?ixlib=rb-1.1.0&rect=19%2C0%2C4397%2C2876&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Buffett's first hit, 'Come Monday,' was written when the artist was deeply depressed and suicidal.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/devore-ca-musician-jimmy-buffett-performs-at-the-1982-us-news-photo/515241080?adppopup=true">Bettmann/Getty Images</a></span></figcaption></figure><p><a href="https://www.nytimes.com/2023/09/02/arts/jimmy-buffett-dead.html">With the death of Jimmy Buffett</a>, the feathers of his loyal network of fans – affectionately <a href="https://www.fox19.com/story/22856369/the-term-parrot-head-coined-at-kings-island-in-1985/">known as Parrot Heads</a> – collectively drooped. </p>
<p>Over the course of his career, Buffett earned their love by transforming himself into a kind of musical shaman who offered transport from the banalities of everyday life to the bounty of a never-never land of eternal sun, endless sandy beaches and bottomless boat drinks: <a href="https://www.nytimes.com/2016/04/24/business/media/jimmy-buffetts-margaritaville-is-a-state-of-mind-and-an-empire.html">Margaritaville</a>.</p>
<p>As a young fan in the 1980s and 1990s, I marveled at the power of Buffett’s music to carry his audience to this fantastic utopia, seeing in it nothing more than a bit of harmless fun.</p>
<p>But as I matured <a href="https://scholar.google.com/citations?user=ZAe9GDcAAAAJ&hl=en">and eventually became a professor of philosophy</a>, I came to see Buffett’s music as less an expression of optimistic pleasure-seeking and more a reflection of a profoundly pessimistic assessment of the trials and tribulations of life. Now his work strikes me as a closer companion to the pessimistic conclusions of the 19th-century philosopher <a href="https://plato.stanford.edu/entries/schopenhauer/">Arthur Schopenhauer</a> than to <a href="https://iep.utm.edu/hedonism/">the hedonism of leisure culture</a>. </p>
<p>I see this hidden pessimism – which underlies most of Buffett’s music – as the key to its enduring power and allure. </p>
<h2>An escape to Saint Somewhere</h2>
<p>Half troubadour and half travel agent, Buffett has long been in the business of selling escape. </p>
<p>Escapism was not only the driving force and centerpiece of his 30 studio albums and the main plotline of his three novels. It was also the heart and soul of <a href="https://www.nytimes.com/2016/04/24/business/media/jimmy-buffetts-margaritaville-is-a-state-of-mind-and-an-empire.html">his billion-dollar business empire</a>, which included two restaurant chains, <a href="https://www.margaritavillefoods.com/products.html?category=82">a line of frozen dinners</a> and a fleet of hotels and casinos. </p>
<p>These myriad products, as their varied taglines and marketing campaigns tout, promise to carry their consumer away from the monotony of suburbia to the galleys of some imaginary Caribbean Island – “Saint Somewhere,” as Buffett put it in his 1979 hit “<a href="https://genius.com/Jimmy-buffett-boat-drinks-lyrics">Boat Drinks</a>.” </p>
<p>Buffett readily admitted his commitment to supplying his fans with some relief from reality. In <a href="https://www.youtube.com/watch?v=PhYrDHUD34c">his 2004 appearance</a> on “60 Minutes,” he gleefully professed, “I sell escapism.” <a href="https://vault.si.com/vault/2007/02/16/the-ballad-of-the-worlds-luckiest-guitar">When interviewed by Sports Illustrated in 2007</a> he said, “I’m just doing my part to add a little more escapism to an otherwise crazy world.” </p>
<p>The question remains, however: Why are people so consistently drawn to Buffett’s special brand of escapism? Or to escapism in general? </p>
<p>Answering this question uncovers the pessimistic heart of Buffett’s work.</p>
<h2>Just a little relief</h2>
<p>Buffett himself ventured an answer to this question in the afterword of his 2004 novel, “<a href="https://www.jimmybuffett.com/books/a-salty-piece-of-land">A Salty Piece of Land</a>”: “… now, more than ever, we don’t just enjoy our escapism – we NEED it.” </p>
<p>For Buffett, escapism was not merely something fun, some fiddling flight of fancy that can be taken up or discarded at will. </p>
<p>It is something essential to our survival – something that, as he put it in his 1974 track “<a href="https://www.lyrics.com/lyric/885165/Trying+to+Reason+With+Hurricane+Season">Trying to Reason with the Hurricane Season</a>,” “cleans [us] out” so that it’s possible to move on with life. </p>
<p>To love the music of Jimmy Buffett, in other words, is not to love life. It is to pessimistically admit that life is difficult and that it needs to be escaped every once in a while just to be endured.</p>
<p>In Buffett’s music one catches a glimpse, however fleeting and even false, of the possibility that somewhere out there, somewhere beyond the persistent struggles and disappointment of life, there lies “somewhere warm,” as he puts it: some utopia where all our fears and anxieties might be wiped away and we can heal from whatever grieves us, whether the heartache of a breakup or the trauma <a href="https://genius.com/Jimmy-buffett-margaritaville-lyrics">of having</a> “[blown] out a flip-flop,” or “stepped on a pop top.”</p>
<p>“When I look out at my audience,” Buffett noted <a href="https://content.time.com/time/subscriber/article/0,33009,988920-2,00.html">in a 1998 interview with Time magazine</a>, “I see people who are caring for aging parents and dealing with tough jobs, adolescent kids, and they look like they could use a little relief.” </p>
<p>And that’s what he endeavored to give them: a little relief from the woes and worries of their lives.</p>
<h2>The role of good art and good music</h2>
<p>Buffett’s first big hit, “<a href="https://www.lyrics.com/lyric/885400/Jimmy+Buffett/Come+Monday">Come Monday</a>,” originated from his own need to escape a particularly dark period of life. </p>
<p>“I was deathly depressed and living in Howard Johnson’s in Marin County,” <a href="https://www.cnn.com/2023/09/02/entertainment/jimmy-buffett-death/index.html">he confessed to David Letterman in 1983</a>, “and this song kept me from killing myself.” </p>
<p>Fortunately, he explained to Letterman, “it hit, and I was able to pay my rent and get my dog out of the pound.” It was his capacity to respond to the overwhelming difficulties of life in this spirit of comedic melancholia that made Buffett’s music so special. </p>
<p>His songs acknowledge what everyone already knows to be true: that life can be excruciatingly painful and is often too much to bear, but that one must nevertheless <a href="https://www.goodreads.com/quotes/114547-you-must-go-on-i-can-t-go-on-i-ll-go">find a way to move on</a>. It is this pessimistic subtext to Buffett’s escapism that made it so achingly irresistible.</p>
<p>In this sense, Buffett’s music exemplifies what the 19th-century pessimistic philosopher <a href="https://plato.stanford.edu/entries/schopenhauer-aesthetics/">Arthur Schopenhauer thought of as the ultimate power of art</a>. </p>
<p>To Schopenhauer, good art grows from a recognition of the difficulties of life, and it endeavors to respond to them by offering a momentary respite from its otherwise relentless slings and arrows. </p>
<p>For these reasons, Schopenhauer saw in art – and in music, especially – a way of escaping reality, of being carried away into a fantasy land that everyone knows can never exist, but that is nonetheless comforting to contemplate. </p>
<p>The value of art, according to Schopenhauer’s pessimistic perspective, comes from how it creates an imaginary space where one can momentarily hide from reality to summon the courage to continue on – and perhaps to even learn from that hiatus how to laugh at the gallows that confront every living creature.</p>
<p>By this pessimistic measure, Buffett’s music was high art, for what it did so well was to help its listeners to escape the onslaught of modern life and teach them to laugh again – not in hedonistic ignorance of its difficulties, but in spite of them. What Buffett and all of his fans secretly know is that such escapist reveries are not merely an optional lark but a necessary tool for survival. </p>
<p>As Buffett himself put it in his 1977 hit “<a href="https://genius.com/Jimmy-buffett-changes-in-latitudes-changes-in-attitudes-lyrics">Changes in Latitudes, Changes in Attitudes</a>,” “If we couldn’t laugh we would all go insane.”</p><img src="https://counter.theconversation.com/content/213043/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Drew M. Dalton does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For Buffett, escapism was not merely some fiddling flight of fancy. It acknowledged the brutalities and indignities of everyday life.Drew M. Dalton, Professor of Philosophy, Dominican UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2108102023-08-07T20:01:51Z2023-08-07T20:01:51ZPictures of pain: how a visual chatbot can help people with chronic pain<p>Chronic or persistent pain is the main reason people seek medical care in Australia. Yet, most chronic pain is incurable and relies on education, exercise and other interventions for management, making it a <a href="https://www.deloitte.com/au/en/services/economics/analysis/cost-pain-australia.html">complex, common and expensive health challenge</a>.</p>
<p>The challenge is more pronounced in the treatment of children and people with diverse needs, such as those with language deficits and varying learning abilities. </p>
<p>Our team of researchers from <a href="http://aehrc.csiro.au">CSIRO</a>, <a href="https://recover.centre.uq.edu.au/">RECOVER Injury Research Centre</a>, the <a href="https://metronorth.health.qld.gov.au/rbwh/healthcare-services/persistent-pain">Tess Cramond Pain and Research Centre</a> and the <a href="https://www.childrens.health.qld.gov.au/service-queensland-interdisciplinary-paediatric-persistent-pain/">Queensland Interdisciplinary Paediatric Pain Service</a> are exploring how therapeutic chatbots can help improve communication between people with chronic pain and health professionals.</p>
<p>To do this, we built a chatbot called <a href="https://twitter.com/RecoverResearch/status/1394776246525960195">Dolores</a>, with a unique feature: a canvas for users to describe their pain with drawings, sketches and doodles. We found that in this case, a picture truly is worth a thousand words. </p>
<h2>About Dolores</h2>
<p>Dolores’s main function is to help users report data on their own pain and provide personalised education. This can be used to enhance communication between users and health professionals and improve pain management.</p>
<p>Dolores is designed to prompt the user for more information, ask follow-up questions, and generally lead the conversation. </p>
<p>The chatbot tailors its responses to the user. It will respond to children with short answers and a limited vocabulary, and responses will gradually increase in complexity with the user’s age.</p>
<p>As the app often captures sensitive data, it was designed with privacy and ethical considerations in mind.</p>
<p>The technology behind Dolores is very different from the large language models behind chatbots such as <a href="https://theconversation.com/chatgpt-isnt-the-death-of-homework-just-an-opportunity-for-schools-to-do-things-differently-205053">ChatGPT</a>. It works from a knowledge base and conversation flow built by occupational, speech and physio therapists, based on diverse experience with clients of different ages. </p>
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Read more:
<a href="https://theconversation.com/aristotle-and-the-chatbot-how-ancient-rules-of-logic-could-make-artificial-intelligence-more-human-142811">Aristotle and the chatbot: how ancient rules of logic could make artificial intelligence more human</a>
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<p>Dolores’s “brain” was built with help from hackathons and industry experts to ensure its responses are always focused on meeting the needs of users. Importantly, it will not give incorrect information or “hallucinate” responses.</p>
<h2>Pain history</h2>
<p>One thing Dolores is used for is to administer what is called a “pain history interview”. </p>
<p>In this process, Dolores asks questions about the onset, location and duration of the user’s pain. It also asks about the sensations and emotions associated with the pain and its impact on daily life, as well as the user’s understanding of pain and their perceptions of different kinds of treatment.</p>
<p>The user can respond to Dolores by talking, typing or drawing. Dolores then produces a transcript which the user can choose to share with their medical professional. </p>
<p>The transcript below was generated using speech recognition from a conversation with an individual living with chronic pain.</p>
<blockquote>
<p><strong>Dolores</strong>: Could you describe or draw what your pain physically feels like?</p>
<p><strong>Client</strong>: Sometimes it’s different … it’s not all the same … then all the days it’s burning tingling </p>
<p><strong>Dolores</strong>: Could you tell me or draw how your pain makes you feel? Physically and mentally.</p>
<p><strong>Client</strong>: Shit makes me feel like shit </p>
<p><strong>Dolores</strong>: And how long have you been in pain for?</p>
<p><strong>Client</strong>: Since I was about 15 years old</p>
<p><strong>Dolores</strong>: Can you tell me or draw how your pain began?</p>
<p><strong>Client</strong>: I am not sure it just began</p>
<p><strong>Dolores</strong>: And how does your pain affect your day-to-day life?</p>
<p><strong>Client</strong>: It affects everything even down to driving, shopping, taking my kids to school. Even just making a cup of tea</p>
<p><strong>Dolores</strong>: What do you believe is the cause of your pain?</p>
<p><strong>Client</strong>: Autoimmune disease and follow on disorders from that</p>
<p><strong>Dolores</strong>: What do you believe are the best treatments for managing your pain?</p>
<p><strong>Client</strong>: Nothing really helps it’s just a matter of learning to deal with it and manage it</p>
</blockquote>
<p>While this example was verbal and detailed, some users – particularly children and adolescents – preferred to doodle. For example, a volcano erupting symbolised a pain flare-up; lightning strikes symbolised sharp, sudden pain; and swirls and waves symbolised cyclic pain. </p>
<p>When asking about the impact of pain on daily life, we received an abundance of stick figures and faces depicting sorrow and loss of identity. </p>
<h2>The future</h2>
<p>In its present state, Dolores can interpret the colours used in a drawing, but not the drawing itself. <a href="https://pubmed.ncbi.nlm.nih.gov/25822055/">Research</a> shows red and black, for example, are commonly used when “painting pain”.</p>
<p>So when soliciting more information about a doodle, Dolores might say things like “That’s a lot of red. What is it?” </p>
<p>The next version of Dolores will have sketch recognition, which we believe will give her more insight and provide extended engagement with clients. </p>
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Read more:
<a href="https://theconversation.com/introducing-edna-the-chatbot-trained-to-help-patients-make-a-difficult-medical-decision-150847">Introducing Edna: the chatbot trained to help patients make a difficult medical decision</a>
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<p>Dolores was received positively in cohorts of patients across different age groups. It will soon be used in the broader chronic pain intervention platform, <a href="https://recover.centre.uq.edu.au/pain-roadmap-mobile-app-help-people-chronic-pain">Pain ROADMAP</a>. </p>
<p>Dolores is a step forward in catering for clients and communities whose language may differ from the clinician and for children and individuals with language disorders, who often have <a href="https://www.spectrumnews.org/news/autistic-children-disproportionately-affected-by-chronic-pain/">higher rates of chronic pain</a> and have difficulties communicating about their pain. </p>
<p>We believe a chatbot that identifies and conveys the symbols of pain to a clinician can be an effective tool for enhanced communication, leading to more effective pain management.</p><img src="https://counter.theconversation.com/content/210810/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Andrews is affiliated with RECOVER Injury Research Centre, The University of Queensland and the Tess Cramond Pain and Research Centre, Metro North Hospital and Health Service.</span></em></p><p class="fine-print"><em><span>David Ireland does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A chatbot that lets users express their feelings by drawing may help communication and treatment for people with chronic pain.David Ireland, Senior Research Scientist at the Australian E-Health Research Centre, CSIRONicole Emma Andrews, Research Fellow, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2098232023-08-04T15:14:48Z2023-08-04T15:14:48ZWhy pain is so hard to measure – and how our study of brainwaves could help<figure><img src="https://images.theconversation.com/files/540190/original/file-20230731-23-k581ux.jpg?ixlib=rb-1.1.0&rect=0%2C30%2C6669%2C4335&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/neck-pain-muscle-stress-strain-concept-2261573651">Prostock-studio/Shutterstock</a></span></figcaption></figure><p>Every individual’s experience of pain is unique – but that makes it harder to treat. The experience of pain remains impenetrable to scientists because it is so variable. So researchers and clinicians still rely on subjective ratings, such as asking patients to rate their pain on a scale of zero to ten.</p>
<p>But my <a href="https://doi.org/10.1152/jn.00530.2021">recent work</a>, in collaboration with my colleague Enrico Schulz and his team, showed new insights into a type of brainwave called gamma oscillations that scientists think may be linked to pain perception. </p>
<p>For the first time, we showed that gamma oscillations differ greatly between people, but that people’s response pattern to pain stayed the same over time. In other words, people who show no waves when in pain will probably not show them in a subsequent recording (when experiencing pain again), whereas those who show a large response will probably show it again. </p>
<p>Pain is variable by definition: the International Association for the Study of Pain <a href="https://www.iasp-pain.org/publications/free-ebooks/classification-of-chronic-pain-second-edition-revised/">defines it as</a> a personal, unpleasant sensory and emotional experience that is influenced by biological, psychological and social factors. </p>
<p>Pain is often different in quality (dull, sharp, shocking, throbbing) and it may be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693173/">hard to remember properly</a>. To complicate matters, although nociception (the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5901905/">unconscious processing</a> of unpleasant stimuli) usually leads to pain, research shows that one can exist without the other. </p>
<p>An objective marker of pain would bypass the distortions caused by cognitive and social factors. And it would help patients who cannot communicate (such as those in a vegetative state) as well as young children and babies.</p>
<h2>The long search for a pain gauge</h2>
<p>Over the past few decades, technological advancements gave researchers the opportunity to finally start developing an objective measurement of pain. </p>
<p>In the early 1990s, neuroimaging techniques such as PET scans and fMRIs became a popular way to study pain. This led to a focus on physiological measures of brain activity. </p>
<p>Scientists became excited by the idea of identifying some sort of “pain centre” or “pain network” within the brain. However, <a href="https://doi.org/10.1016/j.pneurobio.2010.10.005">studies of the brain activation</a> during pain experiments showed that even innocuous stimuli (for example, warmth, touch or vibration when participants weren’t expecting it) can activate the brain similarly to painful stimuli. </p>
<p>Studies have also shown that the brain’s response to painful heat is strongly influenced by the person’s level of <a href="https://pubmed.ncbi.nlm.nih.gov/14678844/">alertness and attention</a>. Both your brain response and your conscious perception of pain are influenced by how much attention you pay to it. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/540781/original/file-20230802-8820-2qyg0z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Female doctor giving injections to a young boy" src="https://images.theconversation.com/files/540781/original/file-20230802-8820-2qyg0z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540781/original/file-20230802-8820-2qyg0z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540781/original/file-20230802-8820-2qyg0z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540781/original/file-20230802-8820-2qyg0z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540781/original/file-20230802-8820-2qyg0z.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540781/original/file-20230802-8820-2qyg0z.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540781/original/file-20230802-8820-2qyg0z.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Everyone’s experience of pain is different.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/indian-female-doctor-giving-injections-young-1978814144">Clovera/Shutterstock</a></span>
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</figure>
<p><a href="https://doi.org/10.1016/j.neucli.2012.06.003">There is growing evidence</a> that brain response to pain doesn’t always have a meaningful relationship to the level of pain a person is experiencing – heightened brain activity doesn’t always mean heightened pain. Contextual factors, study methodology and biological differences between people can all affect brain activity. </p>
<p>So, it became clear that technology alone wouldn’t give us an objective measure of pain. Researchers needed to understand more about the brain’s response to stimulation. </p>
<h2>Brain oscillations</h2>
<p>Decades of research have shown the type of brainwave called gamma oscillations are a good measure of <a href="https://pubmed.ncbi.nlm.nih.gov/25770854/">human response to stimulus in general</a>, not just pain. In the 2000s, experimental work showed that gamma oscillations increased in amplitude following <a href="https://www.jneurosci.org/content/27/35/9270">both brief</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/25754338/">prolonged thermal painful stimuli</a> in healthy volunteers.</p>
<p>Gamma oscillations may control the connectivity between different brain regions. <a href="https://onlinelibrary.wiley.com/doi/full/10.1002/hbm.24373">Patient research</a> and <a href="https://academic.oup.com/cercor/article/28/10/3650/4210990">recording of electrical activity</a> within the brain seemed to support the idea that <a href="https://journals.plos.org/plosbiology/article?id=10.1371/journal.pbio.0050133">gamma oscillations could reflect pain perception</a> better than any other <a href="https://pubmed.ncbi.nlm.nih.gov/22649223/">brain response to pain</a>. </p>
<p>Our <a href="https://doi.org/10.1152/jn.00530.2021">recent work</a> has demonstrated how gamma waves synchronised with painful thermal stimulation are unique to each person. For our experiment, we briefly induced pain using a thermal laser in 22 healthy male volunteers in their 20s and 30s, then recorded their gamma wave responses. This not only pinpointed the extreme variability in people’s gamma waves, but also showed that a person’s response pattern is stable across time. </p>
<p>Our analysis of a <a href="https://www.pnas.org/doi/full/10.1073/pnas.2116616119">separate study</a> published in 2021, independent from ours but using similar methodology, also demonstrated variability between participants in their gamma wave response. </p>
<h2>What our results mean</h2>
<p>The more we understand about people’s unique response to pain, the closer we can get to giving them the right pain relief. </p>
<p>Our findings suggest we must rethink our interpretation of the relationship between pain and gamma oscillations, but that it’s still too early for general rules. Some people will feel pain and have no gamma response, while others will show a large response. </p>
<p>It is also important to remember that brain mechanisms triggered by experimental pain in young healthy people are not necessarily the same as those who have been shaped by long-term pain experience. For example, <a href="https://www.sciencedirect.com/science/article/pii/S0149763421003560">people with chronic pain conditions</a> may have changes in their brain structure and response to pain.</p>
<p>As yet, no clinical trials involving gamma waves have been carried out, perhaps due to technical and <a href="https://www.iasp-pain.org/resources/guidelines/ethical-guidelines-for-pain-research-in-humans/">ethical challenges</a> involved in experiments that study chronic pain patients. </p>
<p>So, we don’t yet know why different people have such different gamma wave responses to pain. But if gamma waves can reliably predict pain in a substantial percentage of the population, we could use this to diagnose, manage and treat pain conditions.</p><img src="https://counter.theconversation.com/content/209823/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elia Valentini does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An objective way to measure pain is the holy grail of pain research. Gamma waves may be part of the answer.Elia Valentini, Senior Lecturer in Psychology, University of EssexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2072222023-06-14T20:11:24Z2023-06-14T20:11:24ZWhy does my back get so sore when I’m sick? The connection between immunity and pain<figure><img src="https://images.theconversation.com/files/531054/original/file-20230609-14782-rgga2o.jpg?ixlib=rb-1.1.0&rect=66%2C0%2C7282%2C4902&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-back-ache-she-sitting-1056416144">Shutterstock</a></span></figcaption></figure><p>Have you ever wondered why your back aches when you’re down with the flu or a cold? Or COVID?</p>
<p>This discomfort, common during many illnesses, is not just a random symptom. It’s a result of complex interactions between your immune system and your brain called the “<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3314453/">neuroimmune synapse</a>”. </p>
<p>A fascinating and yet-to-be-understood consequence of this conversation between the immune and brain systems during sickness is that it is particularly noticeable in the <a href="https://academic.oup.com/brain/article/145/3/1098/6370954">lower back</a>. This is thought to be one of the body’s most sensitive regions to neuroimmune threats.</p>
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Read more:
<a href="https://theconversation.com/turning-down-the-volume-of-pain-how-to-retrain-your-brain-when-you-get-sensitised-202850">Turning down the volume of pain – how to retrain your brain when you get sensitised</a>
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<h2>Immunology basics</h2>
<p>Our immune system is a double-edged sword. Yes, it fights off infections for us – but it also makes us acutely aware of the job it is doing. </p>
<p>When our body detects an infection, our immune system releases molecules including signalling proteins called <a href="https://www.researchgate.net/publication/227831648_The_functions_of_cytokines_and_their_uses_in_toxicology">cytokines</a>. These proteins coordinate our immune system to fight off the infection and talk to our brain and spinal cord to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740752/#:%7E:text=Production%20of%20proinflammatory%20cytokines%20induces,to%20depression%20in%20vulnerable%20individuals.">change our behaviour</a> and physiology. </p>
<p>This can result in symptoms like fatigue, loss of appetite, fever and increased sensitivity to pain. Classically, we think of this as a beneficial behavioural change to help us conserve energy to fight off the infection. It’s why we often feel the need to rest and withdraw from our usual activities when we’re sick – and also why we are grumpier than usual. </p>
<h2>Invisibly small changes</h2>
<p>Part of this self-protective response is a change in how we perceive threats, including sensory stimuli. </p>
<p>When we are sick, touch can become painful and muscles can ache. Many changes in behaviour and sensory systems are <a href="https://doi.org/10.1159/000521476">believed</a> to have origins at the nanoscale. When molecular changes occur in part of the brain linked to cognition or mood, we think and feel differently. If these neuroimmune synapse changes happen in the sensory processing regions of the brain and spinal cord, we feel more pain. </p>
<p>Such sensory changes, known as <a href="https://www.iasp-pain.org/resources/fact-sheets/allodynia-and-hyperalgesia-in-neuropathic-pain/#:%7E:text=Allodynia%20is%20pain%20due%20to,stimulus%20that%20normally%20provokes%20pain.">allodynia and hyperalgesia</a>, can lead to heightened pain sensitivity, even in areas not directly affected by the infection – <a href="https://www.sciencedirect.com/science/article/abs/pii/S0889159114001731?via%3Dihub">such as the lower back</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/531056/original/file-20230609-19-371k1k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="man in bed takes own temperature and holds head" src="https://images.theconversation.com/files/531056/original/file-20230609-19-371k1k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531056/original/file-20230609-19-371k1k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=382&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531056/original/file-20230609-19-371k1k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=382&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531056/original/file-20230609-19-371k1k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=382&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531056/original/file-20230609-19-371k1k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=480&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531056/original/file-20230609-19-371k1k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=480&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531056/original/file-20230609-19-371k1k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=480&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Being sick can make you feel more sensitive to pain and grumpier.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/fever-seasonal-flu-sick-africanamerican-man-1452615326">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Immune memories</h2>
<p>This immune response happens with a range of bacterial infections and viruses like COVID or the flu. In fact, the sick feeling we sometimes get after a vaccination is the good work our immune system is doing to contribute to <a href="https://theconversation.com/you-cant-get-influenza-from-a-flu-shot-heres-how-it-works-118916">a protective immune memory</a>. </p>
<p>Some of that immune-cellular conversation also alerts our brains that we are sick, or makes us think we are. </p>
<p>After some viral infections, the sick feeling persists longer than the virus. We are seeing a long-term response to COVID in some people, termed <a href="https://theconversation.com/when-does-covid-become-long-covid-and-whats-happening-in-the-body-when-symptoms-persist-heres-what-weve-learnt-so-far-188976">long COVID</a>. </p>
<p>Women, who generally have a <a href="https://www.nature.com/articles/nri.2016.90">stronger immune response</a> than men, may be more likely to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7937378/">experience pain symptoms</a>. Their heightened immune response (while beneficial in resisting infections) also predisposes women to a higher risk of inflammatory conditions like <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7980266/">autoimmune diseases</a>. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/you-cant-get-influenza-from-a-flu-shot-heres-how-it-works-118916">You can't get influenza from a flu shot – here's how it works</a>
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<h2>When to worry and what to do</h2>
<p>If the pain is severe, persistent, or accompanied by other concerning symptoms, seek medical attention. Mild to moderate pain is a common symptom during illness and we often notice this in the lower back. The good news is it usually subsides as the infection clears and the sickness resolves.</p>
<p>While treating the underlying infection is crucial, there are also ways to dial down sickness-induced neuroimmune pain. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/531057/original/file-20230609-29-npjpw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="bowl of chicken and vegetable soup" src="https://images.theconversation.com/files/531057/original/file-20230609-29-npjpw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/531057/original/file-20230609-29-npjpw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/531057/original/file-20230609-29-npjpw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/531057/original/file-20230609-29-npjpw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/531057/original/file-20230609-29-npjpw0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/531057/original/file-20230609-29-npjpw0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/531057/original/file-20230609-29-npjpw0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Grandma was right. Eat your soup.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/homemade-chicken-soup-turquoise-bowl-antique-229272709">Shutterstock</a></span>
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<p>Maintaining a diverse microbiome (the collection of microorganisms living in and on your body) by <a href="https://pubmed.ncbi.nlm.nih.gov/31704402/">eating well and getting outside</a> can help. Getting quality sleep, staying hydrated and minimising inflammation <a href="https://karger.com/bbe/article/97/3-4/197/821576/Sickness-and-the-Social-Brain-How-the-Immune">helps too</a>. </p>
<p>Amazingly, there is <a href="https://pubmed.ncbi.nlm.nih.gov/34404209/">research</a> suggesting your grandmother’s traditional chicken broth recipe decreases the immune signals at the neuroimmune synapse. </p>
<p>Scientists are also <a href="https://pubmed.ncbi.nlm.nih.gov/24799686/">showing</a> mindfulness meditation, cold water therapy and controlled breathing can drive profound cellular and molecular changes to help activate bodily systems like the autonomic nervous system and alter the immune response. These practices might not only help manage pain but also add an anti-inflammatory component to the immune response, reducing the severity and duration of sickness. </p>
<p>Heat treatment (with a pack or hot water bottle) might <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8401625/">provide some relief</a> due to increased circulation. Over-the-counter pain relief maybe also be helpful but seek advice if you are taking other medications.</p>
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<strong>
Read more:
<a href="https://theconversation.com/man-flu-is-real-but-women-get-more-autoimmune-diseases-and-allergies-77248">Man flu is real, but women get more autoimmune diseases and allergies</a>
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<h2>All in the mind?</h2>
<p>Is this all mind over matter? A little of yes and a lot of no. </p>
<p>The little of yes comes from <a href="https://pubmed.ncbi.nlm.nih.gov/26194270/">research</a> supporting the idea that if you expect your breathing, meditation and cold bath therapy to work, it may well make a difference at the cellular and molecular level. </p>
<p>But by understanding the mechanisms of back pain during illness and by using some simple strategies, there is hope to manage this pain effectively. Always remember to seek medical help if your symptoms are severe or persist longer than expected. Your health and comfort are paramount.</p><img src="https://counter.theconversation.com/content/207222/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua W Pate is the author of the pain science children's book series titled Zoe and Zak's Pain Hacks.</span></em></p><p class="fine-print"><em><span>Mark Hutchinson is president of Science and Technology Australia and the research laboratory he leads is supported by the Australian Research Council, USDA, AFOSR, Lateral Pharma, Alyra Biotech, Regeneus, DMTC, and Defence Science Technology Group. He is a scientific advisor to Alyra Biotech and has ministerial appointments on the ARC CEO Advisory Committee and ARC legislative review. He has previously received payments for teaching from the NoiGroup.</span></em></p>Our immune system fights infection and has a nifty way to letting our brain know we are sick and should take it easy – but that can also be a pain.Joshua Pate, Senior Lecturer in Physiotherapy, University of Technology SydneyMark Hutchinson, Professor, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2009112023-06-14T02:22:34Z2023-06-14T02:22:34ZSore joints now it’s getting cold? It’s tempting to be less active – but doing more could help you feel better<figure><img src="https://images.theconversation.com/files/526945/original/file-20230518-18-uq5uhz.jpg?ixlib=rb-1.1.0&rect=24%2C453%2C8155%2C5003&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-man-holds-his-hands-knees-2139454187">Shutterstock</a></span></figcaption></figure><p><a href="https://www.health.gov.au/topics/chronic-conditions/what-were-doing-about-chronic-conditions/what-were-doing-about-musculoskeletal-conditions#:%7E:text=In%20Australia%3A,stiff%2C%20painful%2C%20swollen%20or%20deformed">One in three</a> Australians has a musculoskeletal condition involving joint pain, and the most common cause is arthritis. Around <a href="https://arthritisaustralia.com.au/1in7witharthritis/">3.6 million</a> Australians have arthritis and this is projected to rise to <a href="https://www.arthritiswa.org.au/arthritis/australians-in-the-dark-with-arthritis-one-of-our-most-prevalent-and-costly-diseases/#:%7E:text=Arthritis%20is%20a%20leading%20cause,to%205.4%20million%20by%202030">5.4 million by 2030</a>. </p>
<p>For some people with joint pain, cold weather <a href="https://doi.org/10.1186/1471-2474-15-66">seems to make it worse</a>. But temperature <a href="https://doi.org/10.1016/S0304-3959(99)00010-X">is just one factor</a> impacting perceptions of <a href="https://doi.org/10.1097/j.pain.0000000000001776">greater pain</a> during winter. Other factors include those we have some level of influence over, including <a href="https://link.springer.com/article/10.1007/s00702-019-02067-z">sleep</a>, <a href="https://link.springer.com/article/10.1007/s00702-019-02067-z">behavioural patterns, mood</a> and <a href="https://link.springer.com/content/pdf/10.1038/s41598-019-44664-8.pdf">physical activity</a>. Emerging research suggests greater pain levels in winter may also be related to a person’s <a href="https://doi.org/10.1371/journal.pone.0216902">perception of the weather</a>, lack of <a href="https://doi.org/10.1016/j.sjpain.2010.05.030">vitamin D</a> and <a href="https://doi.org/10.1093/rheumatology/kel414">fluctuations in their disease</a>.</p>
<p><a href="https://doi.org/10.1002/msc.1191">Physical activity</a> is one of the best treatments to increase function, strength and mobility – and improve quality of life. It also <a href="https://doi.org/10.1002/msc.1191">promotes</a> mental and physical health and <a href="https://www.sciencedirect.com/science/article/pii/S1466853X21000304?via%3Dihub">reduces the risk</a> of other chronic diseases. </p>
<p>But pain can be a barrier to exercise and activities you’d usually do. So what can you do about it?</p>
<h2>Our brain tries to protect us</h2>
<p>When it comes to pain, our brain is very protective: it’s like an inbuilt alarm system and can warn us about impending danger or harm that has occurred so we can respond. </p>
<p>But it’s not always a reliable indicator of actual damage or trauma to the skin, muscle or bone, even when it feels like it is. In some instances, this warning system can become unhelpful by setting off “false alarms”. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/turning-down-the-volume-of-pain-how-to-retrain-your-brain-when-you-get-sensitised-202850">Turning down the volume of pain – how to retrain your brain when you get sensitised</a>
</strong>
</em>
</p>
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<p>Joint pain and stiffness can also appear to worsen during colder weather, prompting <a href="https://doi.org/10.1177/26335565221100172">fears</a> we could <a href="https://doi.org/10.1002/jor.25151">make it worse</a> if we undertake or overdo movement. This <a href="https://doi.org/10.1016/j.jbspin.2017.07.007">can result in</a> people avoiding physical activity – even when it would be beneficial – which can worsen the pain. </p>
<h2>We tend to exercise less when it’s cold</h2>
<p>Seasons <a href="https://doi.org/10.1016/j.jshs.2016.07.007">affect</a> how much physical activity we get. Summer months bring warmer weather, longer daylight hours and people get outdoors more. Warmer weather also tends to elicit a positive outlook, a lift in mood and burst of physical activity to fulfil New Year’s resolutions. </p>
<p>Cooler months can mean a decline in physical activity and more time being cosy indoors. A reduction in movement and less exposure to light may evoke higher levels of joint pain and can be associated with a reduction in our overall sense of well-being and mood. </p>
<p>This can create a cycle where symptoms worsen over time. </p>
<figure class="align-center ">
<img alt="Older woman exercises with weights" src="https://images.theconversation.com/files/526947/original/file-20230518-19-gzmuv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/526947/original/file-20230518-19-gzmuv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526947/original/file-20230518-19-gzmuv8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526947/original/file-20230518-19-gzmuv8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526947/original/file-20230518-19-gzmuv8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526947/original/file-20230518-19-gzmuv8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526947/original/file-20230518-19-gzmuv8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It can be hard to find the motivation to exercise in winter, especially if you’re experiencing more pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/attractive-elderly-woman-exercising-home-swiss-1212240580">Shutterstock</a></span>
</figcaption>
</figure>
<p>But with the right knowledge and support, people <a href="https://doi.org/10.1080/08870446.2022.2126473">can remain engaged in an active lifestyle</a> especially when it’s aligned to personal values and goals. Health professionals such as physiotherapists and GPs can assess any concerns and provide strategies that are right for you. </p>
<h2>How to motivate yourself to stay active in winter</h2>
<p>When looking for an approach to help you stay active during the cooler months and beyond, it can be helpful to become aware of the many <a href="https://doi.org/10.1002/msc.1191">interconnected factors</a> that impact you. They include:</p>
<ul>
<li>biological (your genes, other illnesses you have)</li>
<li>psychological (how you think, feel and behave) </li>
<li>social (your relationships and social support). </li>
</ul>
<p>Starting with the end goal in mind can be beneficial, but this can feel overwhelming. Try creating smaller, achievable steps to help get you there, like climbing a ladder. For example, park a short distance from the shops and increase this incrementally to increase your exercise tolerance. </p>
<p>A little bit each day can often be less tolling on your body than a big effort once a week.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-i-improve-my-motivation-to-exercise-when-i-really-hate-it-10-science-backed-tips-179761">How do I improve my motivation to exercise when I really hate it? 10 science-backed tips</a>
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</em>
</p>
<hr>
<p>Create goals that are personally meaningful and encourage you to celebrate success along the way (for example, catching up with friends or a healthy snack). Then, as you climb your “ladder”, one rung at a time, you will likely feel more motivated to continue. </p>
<p>If you’re not sure where to start, talk to a friend or health provider to help you determine what is realistic and right for your situation. That way you can <a href="https://doi.org/10.1002/msc.1191">work towards your goals in a safe, non-threatening environment</a> and avoid developing fear and avoidance. They can also help you establish goals that align with your aspirations and pain experience.</p><img src="https://counter.theconversation.com/content/200911/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charlotte Ganderton receives funding from Arthritis Australia, Physiotherapy Research Foundation, Swinburne University of Technology, National Institute of Circus Arts and La Trobe University. Charlotte Ganderton is a member of the Australian Physiotherapy Association and Sports Medicine Australia.</span></em></p><p class="fine-print"><em><span>Inge Gnatt has received funding from Swinburne University's DVCR Writing Award, and is the recipient of an Australian Government Research Training Program Scholarship. </span></em></p><p class="fine-print"><em><span>Matthew King receives funding from the Physiotherapy Research Foundation, Australian Physiotherapy Association, La Trobe University and the Transport Accident Commission. He is affiliated with the Australian Physiotherapy Association, Sports Medicine Australia and the International Hip-related Pain Research Network.</span></em></p>For some people with joint pain, cold weather seems to make it worse. And pain can be a barrier to exercise and activities you’d usually do.Charlotte Ganderton, Senior Lecturer (Physiotherapy), RMIT UniversityInge Gnatt, Lecturer (Psychology), Provisional Psychologist, Swinburne University of TechnologyMatthew King, Lecturer, Research Fellow, and Physiotherapist, La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2013892023-06-11T20:52:50Z2023-06-11T20:52:50ZWhat’s a TENS machine? Can it help my period pain or endometriosis?<figure><img src="https://images.theconversation.com/files/529235/original/file-20230531-17-nf3bmd.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-close-view-girl-touch-stomach-1354368302">Shutterstock</a></span></figcaption></figure><p>If you’ve been on social media recently you might have noticed sponsored posts and ads for a variety of small, portable electrical devices. These claim to manage period or <a href="https://www.endometriosisaustralia.org/about-endo">endometriosis</a> pain safely and without drugs.</p>
<p>Most devices have a small box that generates an electrical pulse, and wires connected to sticky pads, which go on your tummy.</p>
<p>So how are these devices supposed to stop your pain? Are they safe? Do they actually work?</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CT7o8DnPaXs","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-are-painful-periods-normal-62290">Health Check: are painful periods normal?</a>
</strong>
</em>
</p>
<hr>
<h2>They’re mini TENS machines</h2>
<p>These devices use “transcutaneous electrical nerve stimulation”, better known as TENS. In other words, they apply small electrical pulses across the skin to stimulate certain types of nerves.</p>
<p>TENS machines are not new. They’ve been around since the <a href="https://patents.google.com/patent/US3817254">1970s</a> and have been used for a <a href="https://www.healthdirect.gov.au/tens">variety of painful conditions</a>, from muscular injuries to pain relief in labour. </p>
<p>However, these latest devices are compact and easy to wear discretely compared to the older models. They’re fairly simple to use, portable, you can use them at home, and they cost around A$50-200. </p>
<p>It’s easy to see why devices like these might be popular. <a href="https://doi.org/10.1016/j.jpag.2020.11.007">Half</a> of people with period pain say over-the-counter medication such as ibuprofen doesn’t get rid of their period pain. Most people with endometriosis <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/imj.15494">report</a> major issues with getting adequate pain relief.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-sharp-butt-pains-to-period-poos-5-lesser-known-menstrual-cycle-symptoms-191352">From sharp butt pains to period poos: 5 lesser-known menstrual cycle symptoms</a>
</strong>
</em>
</p>
<hr>
<h2>How might TENS work?</h2>
<p>All TENS-based devices generate small electrical pulses that feel a little like <a href="https://patient.info/treatment-medication/painkillers/tens-machines">mild electrical shocks</a>. These pulses are transmitted through the surface of the skin via the sticky pads. </p>
<p>You generally place these pads where the pain is. So for period pain that’s usually at or below the level of the belly button but above the pubic region. You can also place the pads on your lower back or even on your tailbone (sacrum). This is because some nerves near your tailbone also affect the pelvic area.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Sticky pad of TENS machine on skin" src="https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">You place two sticky pads on your tummy or lower back.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/tens-electrodes-positioned-back-pain-treatment-466080803">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Here’s what we know so far</h2>
<p>The exact mechanisms of how TENS works to reduce pain is still unclear. There are likely <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011890.pub3/full">many different pathways</a>. </p>
<p>First, we need to first talk about different types of nerves. <a href="https://www.ncbi.nlm.nih.gov/books/NBK10965/">Nociceptors</a> are nerves that send “danger” impulses about actual or potential tissue damage. Sensory nerves in your skin transmit information about things such as touch and pressure.</p>
<p>The <a href="https://www.science.org/doi/10.1126/science.150.3699.971">gate control theory of pain</a> says the spinal cord has “gates” that can be open or closed. When these gates are open, nerves can transmit these danger impulses up the spinal cord to the brain where they may be interpreted as “pain”. If these gates are closed, these impulses can’t reach the brain as easily.</p>
<p>TENS machines, especially at high frequency (greater than 50 pulses per second), tend to stimulate <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011890.pub3/full">sensory nerves</a> (the ones in your skin). These sensory nerves also send signals to your brain, but faster than the danger ones.</p>
<p>These sensory signals can close the “gates” at certain parts of the spinal cord. So if the TENS machine can stimulate enough of these sensory nerves in your skin, it will block at least some of these danger impulses from reaching the brain. The fewer danger impulses that reach the brain, the less pain you are likely to feel.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Closed farm gate across dirt track" src="https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">TENS machines may close the ‘gates’ at certain parts of the spinal cord so fewer ‘danger’ impulses reach the brain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-iron-farm-field-gate-red-2260337685">Shutterstock</a></span>
</figcaption>
</figure>
<p>Then there’s the concept of <a href="https://www.news-medical.net/health/What-are-Endogenous-Opioids.aspx">endogenous opioids</a> as pain relief. These are pain relieving chemicals the body makes itself. </p>
<p>TENS machines stimulate the release of these chemicals, with different types of endogenous opioids released depending on the frequency of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027071/">stimulation</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-pain-and-what-is-happening-when-we-feel-it-49040">Explainer: what is pain and what is happening when we feel it?</a>
</strong>
</em>
</p>
<hr>
<h2>So does TENS work?</h2>
<p><strong>For period pain</strong></p>
<p>A systematic <a href="https://www.sciencedirect.com/science/article/pii/S155083072030286X">review</a> in 2022 found four studies looking at TENS to manage primary dysmenorrhea (period pain that occurs without any physical changes in the pelvis).</p>
<p>There was a significant reduction in period pain when high-frequency TENS (more than 50 pulses per second) was compared to sham TENS (where the machine looks the same but doesn’t deliver a pulse). </p>
<p>This is in line with an older <a href="https://www.cochrane.org/CD002123/MENSTR_transcutaneous-electrical-nerve-stimulation-for-primary-dysmenorrhoea">Cochrane review</a> that found similar benefits. </p>
<p>Pain relieving effects only tend to last while the device is active.</p>
<p><strong>For endometriosis</strong></p>
<p>Endometriosis is where tissue similar to the lining of the uterus is found outside the uterus, commonly in the pelvis. There is only <a href="https://doi.org/10.1016/j.ejogrb.2015.07.009">one</a> study of TENS for pelvic pain due to endometriosis. </p>
<p>This study compared two types of TENS – one using a higher frequency for 20 minutes twice a day, and one using a lower frequency for 30 minutes once per week. Both types used pads placed on the tailbone, and women were told to make the pulses “strong, but comfortable”. </p>
<p>Both types improved pelvic pain, pain after sex, and quality of life, but not period pain. This was a very small study (11 women in each group) and there was no control or placebo group. So we need larger studies with a proper control group before we can be sure if TENS works for endometriosis pain.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-have-painful-periods-could-it-be-endometriosis-101026">I have painful periods, could it be endometriosis?</a>
</strong>
</em>
</p>
<hr>
<h2>Is it safe?</h2>
<p>Most <a href="https://www.sciencedirect.com/science/article/pii/S155083072030286X">studies</a> report no side effects when the pads are used on the abdomen or lower spine.</p>
<p>However, if you turn up the intensity too high it <a href="https://www.tandfonline.com/doi/full/10.2147/IJWH.S220523">can be uncomfortable</a>. You could also get a rash from the adhesive on the pads.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/first-periods-can-come-as-a-shock-5-ways-to-support-your-kid-when-they-get-theirs-177920">First periods can come as a shock. 5 ways to support your kid when they get theirs</a>
</strong>
</em>
</p>
<hr>
<h2>Which one to buy?</h2>
<p>All TENS machines should allow you to change the <em>intensity</em> (how strong the pulse feels). Some also allow you to change the <em>frequency</em> (how often the pulses happen).</p>
<p>If you are going to use the device occasionally (less than 4-5 days per month) you may just need a device that allows you to change the <a href="https://doi.org/10.2522/ptj.20120281">intensity</a>.</p>
<p>To get the best relief, the machine should be turned up high enough so it delivers noticeable pulses, but is not painful. So you need to find your own comfort level.</p>
<p>For period pain, <a href="https://www.tandfonline.com/doi/full/10.2147/IJWH.S220523">high frequency</a> (more than 50 pulses per second) shows better results than low frequency (usually 2-5 pulses per second). So make sure the device you’re thinking of buying is either set to a high frequency or you can change the frequency.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman clutching tummy and head lying on sofa" src="https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many people find it hard to manage period pain. So would TENS help?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sick-muslim-woman-hijab-having-acute-1616145232">Shutterstock</a></span>
</figcaption>
</figure>
<p>For people with endometriosis, it’s a little more tricky. You’ll probably going to want to use the device more often than a few days a month. </p>
<p>Unfortunately, like with taking regular opioid painkillers, with regular TENS use people can become <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027071/">tolerant</a> to its pain-relieving effect, which means it doesn’t work as well as it did when you first started using it.</p>
<p>One possible solution to tolerance is to use <a href="https://academic.oup.com/ptj/article/93/10/1397/2735589">mixed-frequency TENS</a> where both high and low frequencies are alternated. You can also slowly increase the intensity level over time. </p>
<p>TENS also doesn’t work well when people are regular <a href="https://pubmed.ncbi.nlm.nih.gov/6965549/">opioid users</a>. This is important as people with endometriosis are often using <a href="https://www.jmig.org/article/S1553-4650(20)30291-0/fulltext">opioid medications</a> to manage their pain. If you are using opioids regularly, high-frequency TENS is likely to be a <a href="https://academic.oup.com/ptj/article/93/10/1397/2735589">better choice</a>.</p><img src="https://counter.theconversation.com/content/201389/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mike Armour does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>TENS machines for period pain are all over social media. But what are they? And do they work?Mike Armour, Associate Professor at NICM Health Research Institute, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045222023-05-30T12:24:11Z2023-05-30T12:24:11ZYour body naturally produces opioids without causing addiction or overdose – studying how this process works could help reduce the side effects of opioid drugs<figure><img src="https://images.theconversation.com/files/528436/original/file-20230525-27-cw53qp.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2309%2C1299&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Opioid neurotransmitters are located in many areas of the body, including the brain, spine and gut.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/neurotransmitter-release-mechanisms-royalty-free-image/1396888608">ALIOUI Mohammed Elamine/iStock via Getty Images Plus</a></span></figcaption></figure><p>Opioid drugs such as morphine and fentanyl are like the two-faced Roman god Janus: The kindly face delivers pain relief to millions of sufferers, while the grim face drives an opioid abuse and overdose crisis that <a href="https://www.cdc.gov/drugoverdose/deaths/index.html">claimed nearly 70,000 lives</a> in the U.S. in 2020 alone. </p>
<p><a href="https://scholar.google.com/citations?user=LXVL7f0AAAAJ&hl=en">Scientists like me who study pain and opioids</a> have been seeking a way to separate these two seemingly inseparable faces of opioids. Researchers are trying to design drugs that deliver effective pain relief without the risk of side effects, including addiction and overdose.</p>
<p>One possible path to achieving that goal lies in understanding the molecular pathways opioids use to carry out their effects in your body.</p>
<h2>How do opioids work?</h2>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/16082232/">opioid system in your body</a> is a set of neurotransmitters your brain naturally produces that enable communication between neurons and activate protein receptors. These neurotransmitters include small proteinlike molecules like <a href="https://doi.org/10.1124/mol.120.119388">enkephalins and endorphins</a>. These molecules regulate a tremendous number of functions in your body, including pain, pleasure, memory, the movements of your digestive system and more.</p>
<p>Opioid neurotransmitters activate receptors that are <a href="https://www.ncbi.nlm.nih.gov/books/NBK546642/">located in a lot of places</a> in your body, including pain centers in your spinal cord and brain, reward and pleasure centers in your brain, and throughout the neurons in your gut. Normally, opioid neurotransmitters are released in only small quantities in these exact locations, so your body can use this system in a balanced way to regulate itself.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/NDVV_M__CSI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The opioids your body produces and opioid drugs bind to the same receptors.</span></figcaption>
</figure>
<p>The problem comes when you take an opioid drug like morphine or fentanyl, especially at high doses for a long time. These drugs <a href="https://theconversation.com/how-do-drugs-know-where-to-go-in-the-body-a-pharmaceutical-scientist-explains-why-some-medications-are-swallowed-while-others-are-injected-182488">travel through the bloodstream</a> and can activate every opioid receptor in your body. You’ll get pain relief through the pain centers in your spinal cord and brain. But you’ll also get a euphoric high when those drugs hit your brain’s reward and pleasure centers, and that could <a href="https://doi.org/10.1016%2FS2215-0366(16)00104-8">lead to addiction</a> with repeated use. When the drug hits your gut, you may develop constipation, along with other common <a href="https://www.asahq.org/madeforthismoment/pain-management/opioid-treatment/what-are-opioids/">opioid side effects</a>.</p>
<h2>Targeting opioid signal transduction</h2>
<p>How can scientists design opioid drugs that won’t cause side effects?</p>
<p>One approach my research team and I take is to understand how cells respond when they receive the message from an opioid neurotransmitter. Neuroscientists call this process <a href="https://doi.org/10.1097%2FALN.0b013e318238bba6">opioid receptor signal transduction</a>. Just as neurotransmitters are a communication network within your brain, each neuron also has a communication network that connects receptors to proteins within the neuron. When these connections are made, they trigger specific effects like pain relief. So, after a natural opioid neurotransmitter or a synthetic opioid drug activates an opioid receptor, it activates proteins within the cell that carry out the effects of the neurotransmitter or the drug.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/FQFBygnIONU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Cells communicate with one another in multiple ways.</span></figcaption>
</figure>
<p>Opioid signal transduction is complex, and scientists are just starting to figure out how it works. However, one thing is clear: Not every protein involved in this process does the same thing. Some are more important for pain relief, while some are more important for side effects like <a href="https://theconversation.com/pain-and-anxiety-are-linked-to-breathing-in-mouse-brains-suggesting-a-potential-target-to-prevent-opioid-overdose-deaths-174187">respiratory depression</a>, or the decrease in breathing rate that makes overdoses fatal.</p>
<p>So what if we target the “good” signals like pain relief, and avoid the “bad” signals that lead to addiction and death? Researchers are tackling this idea in different ways. In fact, in 2020 the U.S. Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-opioid-intravenous-use-hospitals-other-controlled-clinical-settings">approved the first opioid drug based on this idea</a>, oliceridine, as a painkiller with fewer respiratory side effects.</p>
<p>However, relying on just one drug has downsides. That drug might not work well for all people or for all types of pain. It could also have other side effects that show up only later on. Plenty of options are needed to treat all patients in need.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="drawing depicting a tangle of red, blue and yellow curly and straight lines" src="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1006&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1006&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1006&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This figure shows the structure of Hsp90.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/heat-shock-protein-90-chaperone-complex-royalty-free-illustration/185759601">Laguna Design/Science Photo Library via Getty Images</a></span>
</figcaption>
</figure>
<p>My research team is targeting a protein called <a href="https://doi.org/10.1007/128_2012_356">Heat shock protein 90, or Hsp90</a>, which has many functions inside each cell. Hsp90 has been a hot target in the <a href="https://doi.org/10.3390/ijms221910317">cancer field</a> for years, with researchers developing Hsp90 inhibitors as a treatment for many cancer types. </p>
<p>We’ve found that Hsp90 is also really important in regulating opioid signal transduction. <a href="https://doi.org/10.1074/jbc.m116.769489">Blocking Hsp90 in the brain</a> blocked opioid pain relief. However, <a href="https://doi.org/10.1126/scisignal.aaz1854">blocking Hsp90 in the spinal cord</a> increased opioid pain relief. Our recently published work uncovered more details on exactly how <a href="https://doi.org/10.1126/scisignal.ade2438">inhibiting Hsp90 leads to increased pain relief</a> in the spinal cord.</p>
<p>Our work shows that manipulating opioid signaling through Hsp90 offers a path forward to improve opioid drugs. Taking an Hsp90 inhibitor that targets the spinal cord along with an opioid drug could improve the pain relief the opioid provides while decreasing its side effects. With improved pain relief, you can take less opioid and reduce your risk of addiction. We are <a href="https://reporter.nih.gov/search/zF-FuD_ZC0CFwl6deU7tQw/project-details/10294366">currently developing</a> a new generation of Hsp90 inhibitors that could help realize this goal. </p>
<p>There may be many paths to developing an improved opioid drug without the burdensome side effects of current drugs like morphine and fentanyl. Separating the kindly and grim faces of the opioid Janus could help provide pain relief we need without addiction and overdose.</p><img src="https://counter.theconversation.com/content/204522/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Streicher receives funding from the National Institutes of Health, the Arizona Biomedical Research Commission, the Flinn Foundation, and the University of Arizona. He is an equity holder in Teleport Pharmaceuticals, LLC, and Botanical Results, LLC, however, no company products or interests were discussed in this article. </span></em></p>Unlike opioid drugs like morphine and fentanyl that travel throughout the body, the opioids your body produces are released in small quantities to specific locations.John Michael Streicher, Associate Professor of Pharmacology, University of Arizona Health SciencesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2062532023-05-26T12:30:16Z2023-05-26T12:30:16ZExercise linked to higher pain tolerance – new study<figure><img src="https://images.theconversation.com/files/528555/original/file-20230526-25-9yb6t3.jpg?ixlib=rb-1.1.0&rect=0%2C6%2C4193%2C2785&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The most active participants had the highest pain tolerance overall.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/exercising-outdoors-healthy-active-lifestyle-runners-1811172892">Maridav/ Shutterstock</a></span></figcaption></figure><p>Many benefits come from regularly exercising, including stronger muscles, lower risk of disease and improved <a href="https://www.sciencedirect.com/science/article/pii/S0378512217308563?casa_token=Cnm_No_rsqYAAAAA:g-_jBJ9-4TloWk2FdMuy0i30DDN7sUIfgaCWfT4FZIjg7HzYDbwpUROaNMa-H3Rrl8L9q63K">mental health</a>. But a recent study suggests that exercise may have another unexpected benefit: it might make us more tolerant to pain.</p>
<p>The study, published in the journal PLOS One, found people who regularly exercised had a <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0285041">higher pain tolerance</a> compared with those who hardly exercised. </p>
<p>To conduct their study, the researchers used data from 10,732 participants who’d taken part in the <a href="https://uit.no/research/tromsostudy">Tromsø study</a> – a large study on health and disease that was conducted in Tromsø, Norway. The participants were aged 30 to 87, and just over half were women.</p>
<p>Every participant was assessed twice, eight years apart. During each assessment, they answered questions about their physical activity levels and took part in a <a href="https://www.jpain.org/article/S1526-5900(04)00746-1/fulltext">cold pressor test</a>. This is a <a href="https://link.springer.com/protocol/10.1007/978-1-60327-323-7_13">common method</a> used by researchers to induce pain in a laboratory environment. Participants place their hand in 3°C water for as long as they can. The longer they keep their hand in the water, the greater their pain tolerance.</p>
<p>The researchers found that the more active the participants were, the longer they could keep their hand in the water. In fact, those who were categorised as being very active were able to keep their hand in the water for 115.7 seconds on average compared with 99.4 seconds for the least-active participants. The researchers also found that participants who stayed active or became even more active were able to perform better on average during the second test compared with those who remained inactive.</p>
<p>It’s worth noting, however, that over the eight years between assessments, everyone became less tolerant of pain on average. This change was roughly the same for everyone – whether people were couch potatoes or avid marathoners. But active participants still had higher pain tolerance compared with inactive people, despite this decrease. It’s uncertain why people became less tolerant to pain over time, but it could be because of ageing. </p>
<p>However, we must be cautious when interpreting the findings. Assessing physical activity via self-report is <a href="https://ijbnpa.biomedcentral.com/articles/10.1186/1479-5868-5-56">tricky business</a> as participants may be <a href="https://academic.oup.com/aje/article/161/4/389/92703">tempted to report</a> they’re more physically active than they are in reality. They may also have trouble remembering their physical activities, which can lead to both over- and under-reporting. </p>
<p>The participants were also only asked about their physical activity over the last 12 months, leaving the remaining seven years between assessments unaccounted for in the analyses. This means someone may be classed as sedentary despite having engaged in vigorous physical activity for seven out of the eight years. Such cases may skew the results and lead to a misinterpretation of the outcomes. </p>
<figure class="align-center ">
<img alt="Man lays on his couch with a video game controller in his hand." src="https://images.theconversation.com/files/528562/original/file-20230526-23-5d0ns6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/528562/original/file-20230526-23-5d0ns6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528562/original/file-20230526-23-5d0ns6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528562/original/file-20230526-23-5d0ns6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528562/original/file-20230526-23-5d0ns6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528562/original/file-20230526-23-5d0ns6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528562/original/file-20230526-23-5d0ns6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sedentary people had worse pain tolerance overall on both tests.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/lazy-young-man-playing-video-game-1816833623">New Africa/ Shutterstock</a></span>
</figcaption>
</figure>
<p>Still, this study joins a growing body of research which has shown the <a href="https://www.yvanc.com/Download/TEMPORAIRES/Aerobic_Training_Increases_Pain_Tolerance_in.21.pdf">benefits of physical activity</a> on <a href="https://onlinelibrary.wiley.com/doi/10.1002/ejp.1508">pain tolerance</a>.</p>
<h2>Exercise and pain</h2>
<p>Given these results, it’s interesting to speculate how physical activity may affect pain tolerance. While we do have some ideas why this link exists, we’re still a long way from knowing the complete picture. </p>
<p>One possible explanation for this link could be due to some of the physiological changes that happen after exercising – such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523781/">exercise-induced “hypoalgesia”</a>. This essentially refers to a reduction in pain and sensitivity that people report during and following exercise. A good example of this is the runner’s high, when the body releases its own opioids, called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104618/">endorphins</a>. These hormones bind to the same receptors as opioids, producing a similar pain-reducing effect. </p>
<p>Yet endorphins are only part of the magic behind the runner’s high. Research suggests the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9916354/">endocannabinoid system</a> has similar effects following exercise. This system is a vast cell-signalling network, comprised largely of endocannabinoids and their receptors. These are neurotransmitters produced by the body that are involved in many processes, including regulating sleep, appetite and mood. </p>
<p>Research also suggests they can help us tolerate pain better. Studies show that exercise can increase levels of <a href="https://www.sciencedirect.com/science/article/pii/S0098299718300359?casa_token=0lGsx1O2Xx0AAAAA:XRuDHU0M0Ps3eyMOr3TmyAxrN-MY1-Ha3_qJtWMvjG3Bm4Vw0HMz75knHCS9z12_L65J3MQx">endocannabinoids</a>, which may in turn improve our pain tolerance overall. </p>
<p>But pain is not a purely physiological phenomenon. It’s an experience, and as such, is subject to our psychology as much as our physiology. </p>
<p>It could be argued that exercise brings with it some level of pain – from stitches and muscle aches to that burning sensation you feel when trying to squeeze out that last rep. </p>
<p>Because of this, exercise has the power to change the way we appraise pain. Exposing ourselves to these unpleasant experiences during a workout can <a href="https://www.sciencedirect.com/science/article/pii/S2667137921000072">help build resilience</a> – our ability to <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-022-13070-7">function in the face of stressful events</a>, such as <a href="https://pubmed.ncbi.nlm.nih.gov/32564216/#:%7E:text=Resilience%2C%20grit%20and%20optimism%20were,to%20pain%20threshold%20and%20tolerance.">pain</a>. Physical activity can also build <a href="https://pubmed.ncbi.nlm.nih.gov/37161890/#:%7E:text=Exercise%20increased%20pain%20self%2Defficacy,at%20high%20risk%20of%20bias.">self-efficacy</a> – our belief that we can do certain things despite pain.</p>
<p>Physical activity also <a href="https://www.sciencedirect.com/science/article/pii/S0378512217308563?casa_token=Cnm_No_rsqYAAAAA:g-_jBJ9-4TloWk2FdMuy0i30DDN7sUIfgaCWfT4FZIjg7HzYDbwpUROaNMa-H3Rrl8L9q63K">improves our mood</a>, which in turn makes us more <a href="https://journals.lww.com/pain/_layouts/15/oaks.journals/downloadpdf.aspx?an=00006396-200808310-00018&casa_token=WVYJ7pbmLKYAAAAA:ChS2V62rC0pQj-YCojxde8P01e_5dOaCxFNhwl7eYtfTxFKBV6cWausYd6HZOCZM61ugjCKCjRlu3wtoEj0rl_3_FbbiIA">resistant to pain</a>. Furthermore, exercise helps us learn how to distract ourselves from pain – such as when <a href="https://pubmed.ncbi.nlm.nih.gov/15878297/">we listen to music</a> while running. Regular physical activity can help us overcome <a href="https://link.springer.com/content/pdf/10.1007/s40279-020-01345-1.pdf">fear of pain and movement</a> and allows us to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4993782/">be prepared</a> for the experience of pain. Unsurprisingly, many of these techniques are used as the basis for <a href="https://link.springer.com/article/10.1007/s00296-016-3481-8">pain management techniques</a>. </p>
<p>While there are still many questions that future research will need to answer, this research reminds us just how beneficial exercise is to us – even in ways we wouldn’t expect. These findings may also add to a growing body of evidence that argues exercise may <a href="https://academic.oup.com/painmedicine/article/14/9/1316/1878250?login=false">help manage chronic pain</a>.</p><img src="https://counter.theconversation.com/content/206253/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nils Niederstrasser does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There are many physiological and psychological reasons why exercise may boost our pain tolerance.Nils Niederstrasser, Senior Lecturer in the Department of Psychology, University of PortsmouthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2062072023-05-25T07:37:59Z2023-05-25T07:37:59ZWhy pain seems worse at night<figure><img src="https://images.theconversation.com/files/527692/original/file-20230523-25-w0efx3.jpg?ixlib=rb-1.1.0&rect=34%2C17%2C5708%2C3811&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/es/image-photo/young-woman-suffering-headache-while-lying-1128432455">Shutterstock / New Africa</a></span></figcaption></figure><p>As the song from the musical <em>Les Miserables</em>, based on the novel by Victor Hugo, says, “But the tigers come at night, with their voices soft as thunder”. We’ve all been miserable at night, when we find ourselves tossing and turning in bed, staring at the ceiling because of an unbearable backache; or toothache, or earache, or kneeache. </p>
<p>It was there during the day, but now it won’t let us rest and gnaws at us. The question is: why do we feel the pain more intensely at night? What does science have to say about it?</p>
<p>Pain is not a strange phenomenon to anyone. But defining it is complicated. After numerous modifications over the years, the International Association for the Study of Pain (IASP) agreed in 2020 to <a href="https://journals.lww.com/pain/Citation/2020/09000/The_revised_International_Assoc%20iation_for_the.6.aspx">narrow it down</a> as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”. </p>
<h2>What is pain for?</h2>
<p>We tend to think of this feeling as something negative, since it is, by definition, an unpleasant experience. But the human being is a complex, finely tuned machine that rarely has functions that are there “just for the sake of it”. </p>
<p>The purpose of pain is to warn us that something is wrong; it is a survival mechanism that helps to keep us safe from dangers that may threaten our physical integrity. To use a simile: it is an alarm system that our brain has to tell us that we are at risk and that urges us to get to safety. And it is unpleasant so that we feel the need to avoid it.</p>
<p>However, it is not a response to a stimulus, <a href="https://www.elsevier.es/es-revista-revista-medica-clinica-las-condes-202-articulo-descartes-su-aporte-al-entendimiento-S0716864014700951">as was thought in Descartes’ time</a> (eg. I touch something burning and the pain saves me from burning because it makes me withdraw my hand). The modern conception understands it as a product of our brain: it is this organ that tells us where, how much and in what way it hurts. </p>
<h2>The Gate Control Theory</h2>
<p>So why does sensation increase at night and how might that help survival?</p>
<p>The explanation has to do with our brain’s processing systems and the science of perception. In the 1960s, Roland Melzack and Patrick Wall proposed their <a href="http://pcpr.pitt.edu/wp-content/uploads/2018/01/Melzack-Wall.pdf"><em>Gate Control Theory</em></a>. According to this, there is a gate in the spinal cord that allows or disallows painful stimuli to pass through to the brain. </p>
<p>In other words, there will be certain things that cause the gate to close and we feel less pain, and other things that cause the gate to open and we feel more pain. An example is the mechanical act of <a href="https://theconversation.com/el-verdadero-poder-de-los-masajes-186571">rubbing our skin if we have been hit</a>: the sensation of friction competes with the sensation of pain and causes it to be felt less. </p>
<p>In the silence of the night, the voices of those tigers are heard more, often as we remember some uncomfortable situation we experienced during the day and had almost forgotten. There is nothing to distract us and help us close the door: no images, no sounds, no interactions with others.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/490059/original/file-20221017-26-bp1ptt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/490059/original/file-20221017-26-bp1ptt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/490059/original/file-20221017-26-bp1ptt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/490059/original/file-20221017-26-bp1ptt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/490059/original/file-20221017-26-bp1ptt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/490059/original/file-20221017-26-bp1ptt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/490059/original/file-20221017-26-bp1ptt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/490059/original/file-20221017-26-bp1ptt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://www.shutterstock.com/es/image-photo/digital-microwave-display-clock-showing-time-1435476089">Shutterstock / lidiasilva</a></span>
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<h2>The worst time? 4am</h2>
<p>Since the 1960s, new theories, new techniques and new findings have been nurturing the science of pain. A study published in <a href="https://academic.oup.com/brain/article/145/9/3225/6637506?login=false"><em>Brain</em></a> last September also points to circadian rhythms as a possible key player in the phenomenon of nocturnal accentuation.</p>
<p>Inès Daguet and her colleagues conducted a novel laboratory study in which they found that the time of day when pain (experimentally induced, in this case) is most intensely perceived is at 4am. One possible explanation is sleep deprivation, as it has also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4046588">been shown to be influential</a>, but in Daguet’s model, the weight of circadian rhythms was much greater. These physical and mental changes we experience may be related to the cyclical levels of hormones we have during the day, such as cortisol, which is related to the immune system and inflammation, and melatonin.</p>
<p>However, it should not be forgotten that this is an experimental study, in a laboratory setting, where participants are not in their natural environment (sleeping in their bed) and receive painful stimuli artificially via a heat-inducing machine.</p>
<h2>Alerts to predator threat</h2>
<p>Researchers Hadas Nahman-Averbuch and Christopher D. King have published <a href="https://www.sciencedirect.com/science/article/pii/S0166223622001825?dgcid=author">a comment</a> on the above study where they point out that from an evolutionary perspective, we are most vulnerable to predators at night, because that is when we sleep. It makes sense, therefore, that a lower intensity of stimuli would be sufficient to wake us up to potential danger.</p>
<p>Ultimately, further research is still needed to understand why we feel more pain at night, but it seems that our brains are still trying to protect us from being eaten by tigers (in this case real ones) while we sleep.</p><img src="https://counter.theconversation.com/content/206207/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rocío de la Vega de Carranza receives funding from the Ministry of Science and Innovation (Spain). </span></em></p>We have all experienced pain becoming more unbearable at night. The absence of stimuli and the influence of circadian rhythms could explain this phenomenon.Rocío de la Vega de Carranza, Investigadora Ramón y Cajal (Psicología), Universidad de MálagaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2059102023-05-22T15:12:55Z2023-05-22T15:12:55ZChronic pain can be objectively measured using brain signals – new research<figure><img src="https://images.theconversation.com/files/527287/original/file-20230519-19-eir5ap.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2040%2C1465&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Researchers are working on untangling the neural circuitry of chronic and acute pain.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/migraine-conceptual-illustration-royalty-free-illustration/1161025033">Victor Habbick Visions/Science Photo Library via Getty Images</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>Using a <a href="https://doi.org/10.1109/TNSRE.2012.2183617">brain implant</a> that can record neural signals over many months, my <a href="https://shirvalkarlab.ucsf.edu">research team</a> <a href="https://scholar.google.com/citations?user=yE7ikcUAAAAJ&hl=en">and I</a> have discovered <a href="https://www.nature.com/articles/s41593-023-01338-z">objective biomarkers of chronic pain severity</a> in four patients with chronic pain as they went about their daily lives.</p>
<p>Pain is one of the most <a href="https://theconversation.com/how-do-painkillers-actually-kill-pain-from-ibuprofen-to-fentanyl-its-about-meeting-the-pain-where-its-at-173804">important and basic subjective experiences</a> a person can have. While there is plenty of evidence that perception of pain <a href="https://www.arthritis.org/health-wellness/healthy-living/managing-pain/understanding-pain/pain-brain-connection">takes place in the brain</a>, there is also a major knowledge gap regarding where and how pain signals are processed in the brain. Even though pain is universal, there has not been a way to objectively measure its intensity. </p>
<p>Most prior studies on the brain signals responsible for pain have relied on <a href="http://dx.doi.org/10.1056/NEJMoa1204471">laboratory experiments in artificial environments</a>. Until now, most research on chronic pain has used indirect measures of brain activity such as <a href="https://www.radiologyinfo.org/en/info/fmribrain">functional magnetic resonance imaging</a> or <a href="https://www.youtube.com/watch?v=tZcKT4l_JZk">electroencephalography</a>. Furthermore, although doctors widely recognize that chronic pain is not just an extension of acute pain – like stubbing your toe – it remains unknown how the brain circuits behind acute and chronic pain relate to each other.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person sitting on couch, holding head in hands." src="https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/527288/original/file-20230519-25-21qk7w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Chronic pain can be debilitating.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/african-american-woman-holds-head-in-hands-on-couch-royalty-free-image/1208951217">Catherine McQueen/Moment via Getty Images</a></span>
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<p>Our study was part of a <a href="https://clinicaltrials.gov/ct2/show/NCT03029884">larger clinical trial</a> aimed at developing a new brain stimulation therapy to treat severe chronic pain. My team surgically implanted electrodes in the brains of four patients with post-stroke pain and <a href="https://www.ncbi.nlm.nih.gov/books/NBK448188/">phantom limb pain</a> to record neural signals in their <a href="https://doi.org/10.1016/j.pneurobio.2004.03.006">orbitofrontal cortex</a>, an area of the brain associated with planning and expectation, and <a href="http://doi.org/10.3171/jns.1962.19.2.0089">cingulate cortex</a>, an area associated with emotion.</p>
<p>We asked the patients about their pain severity levels several times a day for up to six months. We then built machine learning models to try to match and predict each patient’s self-reported pain intensity scores with snapshots of their brain activity signals. These brain signals consisted of electrical waves that could be decomposed into different frequencies, similar to how a <a href="https://doi.org/10.5642/jhummath.201401.05">musical chord can be broken down</a> into individual sounds of different pitches. From these models, we found that <a href="https://www.nature.com/articles/s41593-023-01338-z">low frequencies in the orbitofrontal cortex</a> corresponded with each of the patients’ subjective pain intensities, providing an objective measure of chronic pain. The larger the shift in low-frequency activity we measured, the more likely the patient was experiencing intense pain.</p>
<p>Next, we wanted to compare the relationship between chronic pain and acute pain. We examined how the brain responded to short-term, intense pain caused by applying heat to the patients’ bodies. Based on data from two participants, we found that the anterior cingulate cortex was more involved in <a href="https://www.nature.com/articles/s41593-023-01338-z">processing acute pain</a> than chronic pain. This experiment provides the first direct evidence that chronic pain involves information-processing areas of brain distinct from those involved in acute pain.</p>
<h2>Why it matters</h2>
<p>Chronic pain, defined as pain lasting more than three months, affects <a href="https://doi.org/10.1001/jamanetworkopen.2023.13563">up to 1 in 5 people in the U.S.</a> In 2019, the incidence of chronic pain was more common than that of diabetes, high blood pressure or depression. </p>
<p>Neuropathic pain resulting from damage to the nervous system, such as stroke and phantom limb pain, often doesn’t respond to available treatments and can significantly impair physical and emotional function and quality of life. Better understanding how to measure brain activity to track pain could improve the diagnosis of chronic pain conditions and help develop new treatments such as <a href="https://doi.org/10.3389/fncom.2018.00018">deep brain stimulation</a>. </p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/XCY8uQr2LKo?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Deep brain stimulation has been used to treat severe depression.</span></figcaption>
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<h2>What still isn’t known</h2>
<p>Although our study provides a proof of concept that signals from specific brain regions can serve as an objective measure of chronic pain, it is more likely that pain signals are <a href="http://doi.org/DOI:%2010.1038/srep34853">distributed over a wide brain network</a>. </p>
<p>We still don’t know what other brain regions may harbor important pain signals that may more accurately reflect subjective pain. It is also unclear whether the signals we found would apply to patients with other pain conditions.</p>
<h2>What’s next</h2>
<p>We hope to use these newly discovered neural biomarkers to develop <a href="https://theconversation.com/brain-stimulation-can-rewire-and-heal-damaged-neural-connections-but-it-isnt-clear-how-research-suggests-personalization-may-be-key-to-more-effective-therapies-182491">personalized brain stimulation</a> as a way to treat chronic pain disorders. This approach involves incorporating signals into tailored algorithms that would govern the timing and location of brain stimulation on demand, similar to how a thermostat operates.</p><img src="https://counter.theconversation.com/content/205910/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Prasad Shirvalkar receives funding from the National Institutes of Health BRAIN Initiative and HEAL Initiative, UCSF Weill Neurosciences Institute, and the George and Judy Marcus Fund. He is leading clinical trials for which Medtronic Inc. has donated devices but no direct funding.</span></em></p>Pain has long been subjectively measured, leading to frustrations for patients and doctors alike. Identifying neural biomarkers of pain could improve diagnosis and lead to better treatments of chronic pain conditions.Prasad Shirvalkar, Associate Professor of Anesthesia, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2028502023-04-16T20:04:13Z2023-04-16T20:04:13ZTurning down the volume of pain – how to retrain your brain when you get sensitised<figure><img src="https://images.theconversation.com/files/519223/original/file-20230404-22-zg86ma.jpg?ixlib=rb-1.1.0&rect=23%2C7%2C5152%2C2902&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/close-up-photo-of-a-man-having-a-neck-pain-7298867/">Pexels</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>For every feeling we experience, there is a lot of complex biology going on underneath our skin. </p>
<p>Pain involves our whole body. When faced with possible threats, the feeling of pain develops in a split second and can help us to “detect and protect”. But over time, our nerve cells can become over-sensitised. This means they can react more strongly and easily to something that normally wouldn’t hurt or would hurt less. This is called “<a href="https://sitn.hms.harvard.edu/flash/2022/sensitization-why-everything-might-hurt/#:%7E:text=When%20neurons%20responsible%20for%20sensing,subset%20of%20chronic%20pain%20patients.">sensitisation</a>”.</p>
<p>Sensitisation can affect anyone, but some people may be more prone to it than others due to possible <a href="https://doi.org/10.1111/jabr.12137">genetic factors, environmental factors or previous experiences</a>. Sensitisation can contribute to chronic pain conditions like fibromyalgia, irritable bowel syndrome, migraine or low back pain.</p>
<p>But it might be possible to retrain our brains to manage or even reduce pain.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/one-in-three-people-with-chronic-pain-have-difficulty-accessing-ongoing-prescriptions-for-opioids-182678">One in three people with chronic pain have difficulty accessing ongoing prescriptions for opioids</a>
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<h2>‘Danger!’</h2>
<p>Our body senses possible threats via nerve endings called <a href="https://www.sciencedirect.com/topics/neuroscience/nociceptor">nociceptors</a>. We can think of these like a microphones transmitting the word “danger” through wires (nerves and the spinal cord) up to a speaker (the brain). If you sprain your ankle, a range of tiny chemical reactions start there. </p>
<p>When sensitisation happens in a sore body part, it’s like more microphones join in over a period of weeks or months. Now the messages can be transmitted up the wire more efficiently. The volume of the danger message gets turned way up. </p>
<p>Then, in the spinal cord, chemical reactions and the number of receptors there also adapt to this new demand. The more messages coming up, the more reactions triggered and the louder the messages sent on to the brain.</p>
<p>And sensitisation doesn’t always stop there. The brain can also crank the volume up by making use of more wires in the spinal cord that reach the speaker. This is one of the proposed mechanisms of central sensitisation. As time ticks on, a sensitised nervous system will create more and more feelings of pain, seemingly regardless of the amount of bodily damage at the initial site of pain. </p>
<p>When we are sensitised, we may experience pain that is out of proportion to the actual damage (<a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/hyperalgesia">hyperalgesia</a>), pain that spreads to other areas of the body (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4327510/">referred pain</a>), pain that lasts a long time (<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5573040/">chronic or persistent pain</a>), or pain triggered by harmless things like touch, pressure or temperature (<a href="https://www.ncbi.nlm.nih.gov/books/NBK537129/#:%7E:text=Allodynia%20is%20defined%20as%20%22pain,produce%20sensation%2C%20causing%20pain.">allodynia</a>). </p>
<p>Because pain is a biopsychosocial experience (biological and psychological and social), we may also feel other symptoms like fatigue, mood changes, sleep problems or difficulty concentrating.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="little girl clutches tummy in pain" src="https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/519224/original/file-20230404-22-i5kx7t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Community education about pain might teach good habits from an early age.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/little-asian-girl-have-stomach-ache-2192335661">Shutterstock</a></span>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/for-people-with-chronic-pain-flexibility-and-persistence-can-protect-wellbeing-199008">For people with chronic pain, flexibility and persistence can protect wellbeing</a>
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<h2>Neuroplasticity</h2>
<p>Around the clock, our bodies and brain are constantly changing and adapting. <a href="https://www.ncbi.nlm.nih.gov/books/NBK557811/">Neuroplasticity</a> is when the brain changes in response to experiences, good or bad. </p>
<p>Pain science research suggests we may be able to <a href="https://www.nih.gov/news-events/nih-research-matters/retraining-brain-treat-chronic-pain">retrain</a> ourselves to improve wellbeing and take advantage of neuroplasticity. There are some promising approaches that target the mechanisms behind sensitisation and aim to reverse them.</p>
<p>One example is <a href="https://pubmed.ncbi.nlm.nih.gov/21306870/">graded motor imagery</a>. This technique uses mental and physical exercises like identifying left and right limbs, imagery and <a href="https://www.physio-pedia.com/Mirror_Therapy">mirror box therapy</a>. It has been <a href="https://www.tandfonline.com/doi/full/10.1080/24740527.2023.2188899">tested</a> for conditions like <a href="https://www.ninds.nih.gov/health-information/disorders/complex-regional-pain-syndrome">complex regional pain syndrome</a> (a condition that causes severe pain and swelling in a limb after an injury or surgery) and in <a href="https://www.ncbi.nlm.nih.gov/books/NBK448188/#:%7E:text=Phantom%20limb%20pain%20is%20the,underlying%20pathophysiology%20remains%20poorly%20understood.">phantom limb pain</a> after amputation. Very gradual exposure to increasing stimuli may be behind these positive effects on a sensitised nervous system. While results are promising, more research is needed to confirm its benefits and better understand how it works. The same possible mechanisms of graded exposure underpin some recently developed <a href="https://mhealth.jmir.org/2019/2/e13080/">apps</a> for sufferers.</p>
<p>Exercise can also retrain the nervous system. Regular physical activity can <a href="https://journals.physiology.org/doi/full/10.1152/japplphysiol.01317.2012">decrease the sensitivity</a> of our nervous system by changing processes at a cellular level, seemingly re-calibrating danger message transmission. Importantly, exercise doesn’t have to be high intensity or involve going to the gym. Low-impact activities such as walking, swimming, or yoga can be effective in reducing nervous system sensitivity, possibly by providing new evidence of perceived <a href="https://doi.org/10.1097/j.pain.0000000000002244">safety</a>.</p>
<p>Researchers are exploring whether learning about the science of pain and changing the way we think about it may foster self-management skills, like pacing activities and graded exposure to things that have been painful in the past. Understanding how pain is felt and why we feel it <a href="https://doi.org/10.1111/1756-185X.14293">can help</a> improve function, reduce fear and lower anxiety. </p>
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<a href="https://theconversation.com/health-check-what-causes-headaches-42254">Health Check: what causes headaches?</a>
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<h2>But don’t go it alone</h2>
<p>If you have chronic or severe pain that interferes with your daily life, you should consult a health professional like a doctor and/or a pain specialist who can diagnose your condition and prescribe appropriate active treatments. </p>
<p>In Australia, a range of <a href="https://aci.health.nsw.gov.au/__data/assets/pdf_file/0003/212772/ACI-chronic-pain-services.pdf">multidisciplinary pain clinics</a> offer physical therapies like exercise, psychological therapies like mindfulness and cognitive behavioural therapy. Experts can also help you make lifestyle changes to improve <a href="https://painhealth.csse.uwa.edu.au/pain-module/sleep-and-pain/">sleep</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8584994/">diet</a> to manage and reduce pain. A multi-pronged approach makes the most sense given the complexity of the underlying biology.</p>
<p>Education could help develop <a href="https://www.sciencedirect.com/science/article/abs/pii/S0738399121006467">pain literacy and healthy habits</a> to prevent sensitisation, even from a young age. Resources, such as children’s books, videos, and board games, are being developed and tested to improve <a href="https://doi.org/10.1016/j.jpain.2022.07.008">consumer and community understanding</a>.</p>
<p>Pain is not a feeling anyone should have to suffer in silence or endure alone. </p>
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Read more:
<a href="https://theconversation.com/5-tips-for-building-kids-resilience-after-bumps-scrapes-and-other-minor-injuries-187022">5 tips for building kids' resilience after bumps, scrapes and other minor injuries</a>
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<img src="https://counter.theconversation.com/content/202850/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joshua Pate is the author of the pain science children's book series titled Zoe and Zak's Pain Hacks.</span></em></p>‘Sensitisation’ can affect anyone, but some people may be more prone to it than others due to genetic factors, environmental factors or previous experiences.Joshua Pate, Senior Lecturer in Physiotherapy, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2006632023-03-30T14:58:35Z2023-03-30T14:58:35ZEndometriosis: black women continue to receive poorer care for the condition<figure><img src="https://images.theconversation.com/files/518149/original/file-20230329-18-egi54m.jpg?ixlib=rb-1.1.0&rect=0%2C9%2C6191%2C4105&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Untreated, endometriosis may lead to a range of health problems.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-african-american-woman-feeling-stomach-2080313062">Prostock-studio/ Shutterstock</a></span></figcaption></figure><p>Endometriosis is a common chronic <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(04)17403-5/fulltext">inflammatory condition</a> that affects an estimated one in ten people assigned female at birth. The condition causes tissue similar to the lining of the uterus to grow elsewhere – including on the ovaries, intestines, bladder and bowels. Symptoms can affect the whole body, but often include severe pelvic pain, painful periods, pain during sex, infertility and fatigue. </p>
<p>Sufferers of the condition wait between <a href="https://www.eshre.eu/Guideline/Endometriosis">eight to 12 years</a> on average for a diagnosis. Yet for black women, this picture is even worse – with research showing they’re <a href="https://www.ajog.org/article/S0002-9378(19)30322-9/fulltext">50% less likely</a> to be <a href="https://pubmed.ncbi.nlm.nih.gov/30908874">diagnosed with endometriosis</a> compared to white women.</p>
<p>There are a <a href="https://www.bmj.com/content/379/bmj.o3052.long">number of reasons</a> for why this is the case – including barriers to gynaecological care and systemic racism in the medical field. But this means that black women may suffer for many more years as a result without a proper diagnosis or treatment.</p>
<h2>Racial disparities</h2>
<p>The poorer care that black women receive today for conditions such as endometriosis may actually be linked back to the very beginnings of the field of gynaecology, which has a legacy of <a href="https://ugapress.org/book/9780820354750/medical-bondage/">racism and violent exploitation</a> of black women’s bodies.</p>
<p>For example, J Marion Sims, the 19th-century American doctor who invented the speculum, performed numerous experimental surgeries without anaesthetics on <a href="https://jme.bmj.com/content/medethics/19/1/28.full.pdf">enslaved women who could not consent</a> throughout his career. The reason Sims chose not to use anaesthetic was, in part, because he believed <a href="https://ugapress.org/book/9780820354750/medical-bondage/">black people had higher pain thresholds</a>. </p>
<p>The legacy of this racist myth still persists today. In the US, one study found white medical students and doctors still believe that black patients are biologically <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843483/">less sensitive to pain</a> compared to white patients. And, in the UK, a survey found that <a href="https://www.bmj.com/content/378/bmj.o2337">most black people</a> have experienced prejudice from healthcare professionals when it came to care – including practitioners dismissing their pain. </p>
<p>These biases may partly explain why health professionals, in the US at least, are less likely to provide black women with pain medication <a href="https://pubmed.ncbi.nlm.nih.gov/17197841/">during</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6905121/">after</a> childbirth. Research has also shown that patients of colour consistently receive <a href="https://www.sciencedirect.com/science/article/abs/pii/S1526590009007755">lower quality pain treatment</a> for many different conditions.</p>
<p>Racial disparities in pain treatment are also found in endometriosis care. In the UK, women with <a href="https://cultureandcompassion.com/wp-content/uploads/2015/04/Endometriosis-and-cultural-diversity.pdf">endometriosis from minority ethnic groups</a> are less likely to have their pain believed by clinicians. In the US, almost 72% of patients <a href="https://www.sciencedirect.com/science/article/pii/S0002937821007006?casa_token=kpIEVjkT6SYAAAAA:cY8dIfUhICTXAuLoJ-mBtzLYM5zC1evzXVUlDHhNSvypvpMH2w7B6CsEW0pNQIGZvy8PGHWwhw">diagnosed with endometriosis</a> are white and only around 5% are black. This discrepancy is staggering, especially considering there’s <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9066945/">no definitive evidence</a> endometriosis is more common in white patients. </p>
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<img alt="A young black woman speaks with a male doctor about her concerns." src="https://images.theconversation.com/files/518151/original/file-20230329-23-qr5yul.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/518151/original/file-20230329-23-qr5yul.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/518151/original/file-20230329-23-qr5yul.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/518151/original/file-20230329-23-qr5yul.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/518151/original/file-20230329-23-qr5yul.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/518151/original/file-20230329-23-qr5yul.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/518151/original/file-20230329-23-qr5yul.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Black women are less likely to be diagnosed with endometriosis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/black-woman-visiting-hospital-female-patient-2087553199">Studio Romantic/ Shutterstock</a></span>
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<p>The minority of black women who are diagnosed with endometriosis are diagnosed on average <a href="https://www.medrxiv.org/content/10.1101/2021.07.28.21261303v1.full">two and a half years later</a> than white women. Black women are also less likely to <a href="https://www.sciencedirect.com/science/article/pii/S0002937822000448">receive endometriosis surgery</a> – and if they do, are more likely to experience surgical complications afterwards.</p>
<p>The under-diagnosis of endometriosis in black patients was <a href="https://pubmed.ncbi.nlm.nih.gov/133613/">first identified in the 1970s</a>. Despite this, we still have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9066945/">no reliable estimate</a> of how common endometriosis actually is in black women. This is due to an absence of quality research and the persistent misconception that endometriosis is a “<a href="https://www.routledge.com/The-Makings-of-a-Modern-Epidemic-Endometriosis-Gender-and-Politics/Seear/p/book/9780367078027">white career women’s disease</a>” and is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9066945/">rare in patients of colour</a>. </p>
<h2>Need for change</h2>
<p>This all not only means that black patients wait longer for endometriosis care – they’re less likely to receive care to begin with.</p>
<p>Undiagnosed endometriosis has potentially serious health consequences. Left untreated, endometriosis tissue may continue to grow, causing <a href="https://www.eshre.eu/Guideline/Endometriosis">organ damage</a> to the uterus, intestines, bladder and bowels. This can worsen already severe pelvic pain, and cause painful and extremely heavy periods, pain during sex, alongside bladder and bowel damage – which could lead to incontinence and bowel problems.</p>
<p>Endometriosis may also affect fertility. Almost <a href="https://pubmed.ncbi.nlm.nih.gov/18684448/">half of all cases of infertility in women</a> are potentially caused by endometriosis. <a href="https://www.sciencedirect.com/science/article/pii/S0015028217305393">Risks of pregnancy</a> complications (including <a href="https://www.endometriosis-uk.org/endometriosis-fertility-and-pregnancy">miscarriages</a>) are also higher – particularly when it isn’t known that a patient has endometriosis.</p>
<p>Endometriosis also affects <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7800443/">many aspects of a person’s life</a> – from school attendance and achievements, to relationships, career performance and financial earnings. Without proper care, risks of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7800443/">anxiety, low-self esteem and depression</a> are higher. In rare cases, the risk of <a href="https://academic.oup.com/aje/article/190/5/843/5979508?login=false">self-harm and suicide</a> are also higher for all those with endometriosis.</p>
<p>Much needs to change within the medical community to improve endometriosis and gynaecological care for black women. Mandatory training for health professionals on implicit racial bias, alongside dedicating funding to research investigating the prevalence and impact of endometriosis on black women are just a few of the things <a href="https://www.bmj.com/content/bmj/379/bmj.o3052.full.pdf">we recommend</a> to make this happen. Another shortcoming in relation to black women’s endometriosis care is that the majority of available evidence comes out of the US. This further highlights the need for more research into this area to fully understand what the picture is in other parts of the world.</p>
<p>Black women who suspect they have endometriosis can find resources from organisations like <a href="http://cysters.org/">Cysters</a>, the <a href="https://tapproject.co.uk/black-women-reproductive-health/">Black Women’s Reproductive Health Project</a>, <a href="https://www.endoblack.org/">EndoBlack</a> and the <a href="https://bwhi.org/">Black Women’s Health Imperative</a>. </p>
<p>Pain is not something you must suffer in silence. Keeping <a href="https://www.endometriosis-uk.org/sites/default/files/2022-08/pain-symptoms-diary_0.pdf">a diary of your pain and symptoms</a> you may have as well as a <a href="https://www.endometriosis-uk.org/seeing-endometriosis-specialist">list of questions</a> when talking to your GP.</p><img src="https://counter.theconversation.com/content/200663/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Danielle Perro is affiliated with The Black Women's Reproductive Health Project. </span></em></p><p class="fine-print"><em><span>Annalise Weckesser is affiliated with the Social SciencEs of Endometriosis Network. </span></em></p><p class="fine-print"><em><span>Véronique Griffith receives funding from the British Academy. She is affiliated with the Social SciencEs of Endometriosis Network.</span></em></p>Black women are half as likely to be diagnosed with endometriosis compared to white women.Danielle Perro, Postdoctoral Researcher, Nuffield Department of Women's and Reproductive Health, University of OxfordAnnalise Weckesser, Reader in Medical Anthropology, Birmingham City UniversityVeronique Griffith, Lecturer in Healthcare Sciences, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1990082023-02-23T19:02:03Z2023-02-23T19:02:03ZFor people with chronic pain, flexibility and persistence can protect wellbeing<figure><img src="https://images.theconversation.com/files/511336/original/file-20230221-26-zuo73t.jpg?ixlib=rb-1.1.0&rect=110%2C80%2C6599%2C4386&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/woman-wearing-black-camisole-3356489/">Pexels/Engin Akyurt</a></span></figcaption></figure><p>Chronic pain affects around <a href="https://academic.oup.com/painmedicine/article/14/9/1346/1878427">one</a> in <a href="https://journals.lww.com/pain/Abstract/2022/02000/Prevalence_of_chronic_pain_among_adults_in_the.31.aspx">five</a> people and is considered “chronic” when it persists beyond the expected healing time, typically three months or longer. </p>
<p>Along with physical problems, chronic pain can impact a person’s daily activities, <a href="https://academic.oup.com/fampra/article/34/6/656/3748262">employment, lifestyle</a> and <a href="https://www.ochsnerjournal.org/content/17/2/173.abstract">mental health</a>. </p>
<p>Doing things you love and having goals are fundamental for wellbeing because they give <a href="https://www.sciencedirect.com/science/article/pii/S0165178116318108">meaning and purpose</a>. But pain can make doing the activities you enjoy psychologically, physically and/or <a href="https://psycnet.apa.org/record/2015-14817-002">emotionally</a> very <a href="https://www.sciencedirect.com/science/article/abs/pii/S0304395908004181">challenging</a>. </p>
<p>Our <a href="https://www.mdpi.com/1660-4601/20/2/1278">new research</a> shows the way a person with chronic pain responds to not being able to participate in the activities or goals they value can can impact their <a href="https://www.researchgate.net/publication/327410714_Goal_Adjustment_and_Well-Being_The_Role_of_Optimism_in_Patients_with_Chronic_Pain">mental wellbeing</a> – even more so than their pain levels.</p>
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Read more:
<a href="https://theconversation.com/why-we-need-to-get-creative-when-it-comes-to-talking-about-pain-152257">Why we need to get creative when it comes to talking about pain</a>
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<h2>Pain intensity vs interference</h2>
<p>We surveyed more than 300 people living chronic pain (that wasn’t related to cancer) about their mental wellbeing, “pain intensity” and how much pain interfered with the everyday pursuits and activities that mattered to them. </p>
<p>(We differentiated <a href="https://onlinelibrary.wiley.com/doi/full/10.1034/j.1399-6576.2001.450906.x">chronic pain from cancer pain</a> due to the differing prognoses and treatments available, and the unique psychological and social factors associated with cancer pain, such as concern about death.)</p>
<p>We found pain that disrupted daily life activities, rather than the intensity of the pain, posed the biggest threat to a person’s mental wellbeing. </p>
<p>When pain interferes with a person’s engagement in meaningful daily activities, it causes distress and <a href="https://journals.sagepub.com/doi/abs/10.1177/2049463718824857">decreases wellbeing</a>. </p>
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<img alt="Man's hands with arthritis" src="https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511337/original/file-20230221-14-hyscco.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pain stops some people doing the things they find meaningful, like going to work.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/dNe6TyX_laM">Unsplash/Towfiqu Barbhuiya</a></span>
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<p>The research suggests it’s possible for people to find ways to maintain their mental wellbeing, even when their pain intensity is high, so long as they’re able to maintain aspects of life that are important to them, such as relationships and work.</p>
<h2>People with pain find other ways of doing things</h2>
<p>We found personal motivational traits – specifically, goal flexibility (adjusting goals in response to changing circumstances and setbacks) and tenacity (persistently striving to achieve a desired goal under difficult circumstances) – were associated with increases in mental wellbeing for people living with chronic pain. </p>
<p>Although flexibility and persistence were both associated with increased mental wellbeing, the capacity to flexibly adjust to setbacks or obstacles had the most significant positive effect in maintaining one’s mental wellbeing. </p>
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Read more:
<a href="https://theconversation.com/1-in-5-aussies-over-45-live-with-chronic-pain-but-there-are-ways-to-ease-the-suffering-137891">1 in 5 Aussies over 45 live with chronic pain, but there are ways to ease the suffering</a>
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<p>Flexibility appears to act as a protective factor against the impacts of pain interference on mental wellbeing, to a greater extent than personal tenacity or persistence.</p>
<p>There is often more than one way to modify or adapt an activity when difficulties arise. A walk on the beach with friends, for instance, may be adjusted to meeting at the beach for coffee to fulfil the same goal or value: social connectedness.</p>
<h2>Focusing on people’s strengths rather than deficits</h2>
<p>Psychological processes that can help people to live well in the face of long-term pain have long been overlooked. Research has traditionally focused on unhelpful thought processes that perpetuate or exacerbate mental distress. For example, <a href="https://www.tandfonline.com/doi/full/10.2147/JPR.S64730">pain catastrophising</a> and repeated <a href="https://psycnet.apa.org/record/2015-14817-002">negative</a> <a href="https://pubmed.ncbi.nlm.nih.gov/21283147/">self-criticism</a>.</p>
<p>Pain management and mental health are multi-faceted. Previous research has shown <a href="https://www.sciencedirect.com/science/article/pii/S0007091219302272">pain management</a> should take into account physical factors (age, sleep, injury, disease) and social factors (employment, social support, economic factors).</p>
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<img alt="Older man with walking stick walks next to small white dog" src="https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511340/original/file-20230221-18-9qf476.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Research has tended to focus on the negative thought processes of people with chronic pain, rather than the positive.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/elderly-tall-stooped-man-stick-walks-1808227138">Shutterstock</a></span>
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<p>Our findings add to this body of knowledge. For those living with pain, reappraising and adjusting meaningful life activities and goals, when needed, in response to setbacks or life challenges can help maintain mental wellbeing.</p>
<p>These findings can inform the development of psychological supports for people with chronic pain. In turn, these supports could identify <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590174/">internal strengths</a>, resources, positive coping strategies, self-efficacy, hope and wellbeing – and promote psychological strengths rather than deficits.</p>
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Read more:
<a href="https://theconversation.com/endometriosis-costs-women-and-society-30-000-a-year-for-every-sufferer-124975">Endometriosis costs women and society $30,000 a year for every sufferer</a>
</strong>
</em>
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<img src="https://counter.theconversation.com/content/199008/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joanne Dickson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>New research shows the way a person with chronic pain responds to limitations to the activities or goals they value can impact their mental wellbeing – even more so than their pain levels.Joanne Dickson, Professor of Psychology & Mental Health, Edith Cowan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1989042023-02-06T12:19:57Z2023-02-06T12:19:57ZWhat historic executions in London can tell us about our contemporary appetites for pain and vulnerability<figure><img src="https://images.theconversation.com/files/507600/original/file-20230201-10326-bz77s1.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Jacobite broadside depicting the execution of lords Kilmarnock and Balmerino at Tower Hill in London.</span> <span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/8/82/Jacobite_broadside_-_View_of_Tower_[…]ace_of_execution_of_the_Lords_Kilmarnock_and_Balmerino.jpg">National Library of Scotland</a></span></figcaption></figure><p>Until the mid-19th century in Britain, watching someone die was considered a form of <a href="https://theconversation.com/think-entertainment-is-violent-today-the-victorians-were-much-much-worse-66714">entertainment</a>. Indeed, this shared experience shaped the landscape of London and bound the city together. </p>
<p>Entitled <a href="https://www.museumoflondon.org.uk/museum-london-docklands/whats-on/exhibitions/executions">Executions</a>, the current exhibition at the Museum of London Docklands tells the stories of tens of thousands of Londoners <a href="https://theconversation.com/forget-gory-gunpowder-jacobean-england-had-a-bloodcurdling-appetite-for-violence-86647">executed</a> in public spaces across the city over almost 700 years, from 1196 to 1868 – the official recorded dates of its first and last public execution. </p>
<p>From <a href="https://commons.wikimedia.org/wiki/Category:Gibbet_cages#:%7E:text=English%3A%20A%20gibbet%20cage%2C%20iron,it%20from%20a%20high%20post.">gibbet cages</a> erected on the main streets along the Thames, to <a href="https://www.britannica.com/topic/pillory-penology">pillories</a> displayed for all to see at Charing Cross, and gallows at Tyburn (what is now Marble Arch) and Tower Bridge, public executions were <a href="https://www.historic-uk.com/HistoryMagazine/DestinationsUK/ExecutionSitesinLondon/">a ritual</a> which served several purposes. Learning about this history can offer insight into our contemporary appetite for – and apathy towards – the suffering of others. </p>
<figure class="align-center ">
<img alt="An overhead shot of a metal plaque with an inscription amid paving stones." src="https://images.theconversation.com/files/507567/original/file-20230201-16-dmnifx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/507567/original/file-20230201-16-dmnifx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/507567/original/file-20230201-16-dmnifx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/507567/original/file-20230201-16-dmnifx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/507567/original/file-20230201-16-dmnifx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/507567/original/file-20230201-16-dmnifx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/507567/original/file-20230201-16-dmnifx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Plaque commemorating the 16th-century site of Tyburn gallows near Marble Arch in central London.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/plaque-london-located-near-marble-arch-136589456">Chris Dorney</a></span>
</figcaption>
</figure>
<h2>Material expressions of state power</h2>
<p>Executing someone in public and leaving corpses and other decaying body parts on display for several days (or years, in the case of gibbet cages) worked as a deterrent to crime and rebellion. The gruesome sight and the smell shaped collective memory and were a reminder that nobody could escape the dire consequences of crime. The exhibition shows that no one was spared – from the common man to public figures of the time and, indeed, <a href="https://www.bl.uk/learning/timeline/item103698.html">the King</a>.</p>
<p>In his 1975 book Discipline and Punish, French philosopher Michel Foucault <a href="https://cpb-us-e1.wpmucdn.com/sites.psu.edu/dist/d/37602/files/2016/01/Discipline-and-Punish.pdf">explains</a> that public execution was not just about the “theatre of punishment”. It was also about the material expression of state power – a ceremony through which the hold that the state, the crown and the church exercised over the life and death of citizens was made clear. </p>
<p>Different typologies of crime called for different methods of execution. By the end of the 18th century, in England there were <a href="https://newjurist.com/history-of-capital-punishment.html">220 offences</a> – from treason to pick-pocketing – that were punishable by death. This ruthless penal system became known as the “<a href="https://hummedia.manchester.ac.uk/schools/law/main/research/MSLR_Vol2_3(Evans).pdf">bloody code</a>”. </p>
<p>These executions could be attended by up to 50,000 spectators, bringing significant <a href="https://www.geriwalton.com/a-hanging-known-as-english-open-air-entertainment/">economic gain</a>. Hawkers sold fruit, pies and beverages to the public queuing for hours at the gallows. Window views over the site of the execution were rented to those spectators who could afford them. Print shops distributed “<a href="https://iiif.lib.harvard.edu/manifests/view/drs:4787716$1i">execution broadsides</a>” throughout the country, reporting the last dying speeches of the condemned and reflecting, often in satirical terms, on the nature of their crimes. </p>
<figure class="align-center ">
<img alt="An 18th-century print from a satirical journal depicting two portraits above an engraved scene." src="https://images.theconversation.com/files/507593/original/file-20230201-7613-vyv5pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/507593/original/file-20230201-7613-vyv5pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=942&fit=crop&dpr=1 600w, https://images.theconversation.com/files/507593/original/file-20230201-7613-vyv5pl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=942&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/507593/original/file-20230201-7613-vyv5pl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=942&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/507593/original/file-20230201-7613-vyv5pl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1184&fit=crop&dpr=1 754w, https://images.theconversation.com/files/507593/original/file-20230201-7613-vyv5pl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1184&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/507593/original/file-20230201-7613-vyv5pl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1184&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A satirical execution broadsheet from 1767.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/3/3e/The_Duumvirate_%28BM_1868%2C0808.9764%29.jpg">British Museum</a></span>
</figcaption>
</figure>
<p>In 1722, printer Thomas Gent <a href="https://catalog.loc.gov/vwebv/search?searchCode=LCCN&searchArg=91046370&searchType=1&permalink=y">wrote</a> that, as he was printing the dying speech of Christopher Layer, who had been hanged for treason, he was besieged by hawkers anxious for the publication and was unable to step outside his office until he had finished. </p>
<h2>Public gratification</h2>
<p>Public executions were not just about the sentencing of criminals. They were viewed as events that lasted several days where the hangman, the condemned, the priest and the governor were actors playing roles in a bigger collective spectacle – and where audience gratification was as important an element as the punishment itself. </p>
<p>In 1783, English writer Samuel Johnson was asked where he stood on the subject of public hanging, and whether he would favour the alternative of executing criminals right after the sentence and without public announcement. He did not, <a href="https://www.jstor.org/stable/3483581">replying</a>: “The old method was most satisfactory to all parties; the public was gratified by the procession, the criminal supported by it. Why is all this to be swept away?”</p>
<p>Less than a century later in 1849, however, Charles Dickens witnessed the hanging of <a href="https://core.ac.uk/download/pdf/80690472.pdf">Marie and Frederick Manning</a>, a Swiss maid and her publican husband who were condemned for the murder of Irish customs officer Patrick O'Connor. The letter Dickens subsequently <a href="https://www.charlesdickenspage.com/public-execution.html">wrote</a> to The Times was lamentful:</p>
<blockquote>
<p>I believe that a sight so inconceivably awful as the wickedness and levity of the immense crowd collected at that execution this morning could be imagined by no man, and could be presented in no heathen land under the sun. The horrors of the gibbet and of the crime which brought the wretched murderers to it faded in my mind before the atrocious bearing, looks, and language of the assembled spectators.</p>
</blockquote>
<p>We know from <a href="https://www.cambridgescholars.com/resources/pdfs/978-1-4438-1963-3-sample.pdf">literature</a>, poetry and also <a href="https://www.independent.co.uk/news/science/scientists-prove-it-really-is-a-thin-line-between-love-and-hate-976901.html">science</a> that the line between repulsion and attraction, horror and thrill, sublime and grotesque is fine. What sets the spectacle of public executions apart from these configurations is the staged, yet real, sensationalisation of an authentic tragedy. </p>
<h2>The commodification of pain</h2>
<p>Nowadays, images of death and suffering are routine in <a href="https://theconversation.com/from-tarantino-to-squid-game-why-do-so-many-people-enjoy-violence-170251">popular culture</a>. In the <a href="https://journals.sagepub.com/doi/pdf/10.1177/097325861000400301">age of tele-trauma</a>, pain has been commodified. The suffering individual is lost and repackaged into a fictional other for our consumption.</p>
<p>French philosopher Jean Baudrillard’s <a href="https://eprints.walisongo.ac.id/id/eprint/3868/4/104111026_Bab3.pdf">work</a> shows that consumption has nothing to do with gratifying our needs. Rather, it is the contemporary way in which we relate to one another and to society at large. In processing information from the media, we transform objects (reality) into signs (virtuality) to create alternative value-systems. These form a falsified reproduction of reality which alters public consciousness. </p>
<p>In other words, the media articulation of violent images and language produces specific meaning about the suffering of others. It shapes up specific ways in which we – the audience – engage with those distant and mediated vulnerabilities. This produces a shift in our response to pain and suffering. We move from empathy to apathy.</p>
<p>In the mid-19th century, Dickens was already noting how the spectacle of public execution triggered a collective disconnect from the suffering of others. In his letter to the Times he wrote: </p>
<blockquote>
<p>When the day dawned, thieves, low prostitutes, ruffians, and vagabonds of every kind flocked on to the ground, with every variety of offensive and foul behaviour. There was no more emotion, no more pity, no more thought that two immortal souls had gone to judgement.</p>
</blockquote>
<p>Today we continue to both demonise and crave the vulnerability of others. The difference is that we no longer do it collectively in the public square, but intimately in our homes. It is an exercise which Baudrillard describes, in his 2000 book Screened Out, as a “<a href="https://www.versobooks.com/books/1561-screened-out">great laundering</a>”. By falsely identifying with distant victims of pain from our position of safety, we are able to condone our indifference and overwrite a more edifying, self-absolving story.</p><img src="https://counter.theconversation.com/content/198904/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Caterina Nirta does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Learning about the history of public executions offers insight into our contemporary appetite for – and apathy towards – the suffering of others.Caterina Nirta, Lecturer in Criminology, Royal Holloway University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1892882022-12-22T16:56:00Z2022-12-22T16:56:00ZChronic pain: An invisible disease whose sufferers are unfairly stigmatized<figure><img src="https://images.theconversation.com/files/481359/original/file-20220826-2852-t3iovl.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C667&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even though chronic pain is recognized by scientists as a disease in its own right, it remains largely under-recognized, under-diagnosed and, above all, subject to many prejudices. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Imagine living with pain every day for months, or even years — pain that is so intrusive, it disrupts every day of your life.</p>
<p>Unfortunately, this is the daily reality of millions of people living with chronic pain. And all too often, they find their condition being stigmatized or even denied outright.</p>
<p>As a doctoral student in the epidemiology of chronic pain, I have the opportunity to work with patient partners. Given the high prevalence and multiple impacts of this disease, it is high time we started working to change attitudes and confront the prejudices that surround it.</p>
<h2>Essential pain and acute pain</h2>
<p>Before discussing chronic pain, let’s start at the beginning. Is pain always a negative thing? Of course not. Pain is essential to our proper functioning. It acts as an <a href="https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019/canadian-pain-task-force-June-2019-report-en.pdf">alarm system</a> to warn us of danger.</p>
<p>For example, if we were to accidentally put our hand on a hot stove top, a pain message would be sent to our brain. Before we even had time to think about it, we would remove our hand from the hot surface, avoiding an intense burn in the process. This pain provides us with the reflexes we need in order to avoid the worst situations.</p>
<p>Pain can also last a little longer. This is the case, for example, after an injury, an operation or an infection. <a href="https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019/canadian-pain-task-force-June-2019-report-en.pdf">This pain will often resolve itself after a normal healing cycle</a> or disappear with the help of treatment. This is called acute pain. Short-term pain like this is perceived more as a symptom.</p>
<h2>Chronic pain, a disease with multiple impacts</h2>
<p>When pain persists beyond the normal healing time, it is no longer considered simply a symptom, but a <a href="https://doi.org/10.1097/j.pain.0000000000000160">disease in its own right</a>. This is called chronic pain. Chronic pain is defined as <a href="https://doi.org/10.1097/j.pain.0000000000001384">pain that persists for a minimum of three months</a>. Yet, for the vast majority of people living with this disease, the pain persists for several years.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472372/original/file-20220704-12-5r8qlt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">‘Displacement,’ by Chloe Fleisher, 13, who lives with chronic pain. Submitted as part of the art contest titled ‘Pain and mental health,’ this artwork won an award from the Canadian Pain Society in 2022.</span>
<span class="attribution"><span class="source">(Marimée Godbout-Parent)</span></span>
</figcaption>
</figure>
<p>In these people, the pain message is somehow missing. It is no longer present to warn us of dangers, but becomes a burden on its own. Chronic pain can occur as a result of cancer, an accident, or after surgery. Unfortunately, sometimes we are unable to find the cause. This makes it difficult to treat.</p>
<p>Although this disease is not widely recognized, it is estimated to affect about <a href="https://doi.org/10.24095/hpcdp.31.4.04">20 per cent of the Canadian population</a>. Considering that our population in 2022 is estimated to be close to 39 million, this would mean that approximately 7.5 million people are living with chronic pain. For the purpose of comparison, 7.5 million Canadians is equivalent to <a href="https://worldpopulationreview.com/canadian-provinces/quebec-population">the entire population of Québec</a>. It’s an impressive and worrisome number.</p>
<p>In addition to affecting a large portion of the population, chronic pain <a href="https://www.canada.ca/content/dam/hc-sc/documents/corporate/about-health-canada/public-engagement/external-advisory-bodies/canadian-pain-task-force/report-2019/canadian-pain-task-force-June-2019-report-en.pdf">causes more than just physical pain</a>. The disease affects the daily functioning, psychological well-being, quality of life, social life and work of the people afflicted by it.</p>
<p>Imagine having so much pain that it reduces your ability to work, play with your children, see your friends or concentrate and even affects your ability to carry out everyday tasks. Despite the person’s desire to stay active, the body just can’t keep up. So it’s not surprising that consequences such as fatigue, frustration, sadness, anxiety and depression follow. The constant overlap between physical, psychological and social difficulties creates deep distress in this population.</p>
<h2>A stigmatized disease</h2>
<p>Despite the significant impacts associated with it, <a href="https://doi.org/10.1111/j.1526-4637.2011.01264.x">chronic pain remains largely stigmatized</a>. Indeed, negative attitudes and beliefs that people living with chronic pain <a href="https://doi.org/10.1080/24740527.2017.1369849">have become dependent on their medications, that they are exaggerating the severity of their condition, are just lazy</a> or do not want to help themselves are widespread.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/IcdsYdUls44?wmode=transparent&start=48" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Chronic pain is a very real disease.</span></figcaption>
</figure>
<p>So, knowing the multiple consequences and prevalence of chronic pain, why is there still so much prejudice and stigma towards those who suffer from it?</p>
<p>The question remains unanswered. For some, what we cannot see simply does not exist. Because pain is an experience that varies from person to person, because we don’t have a specific tool for detecting it or because we can’t necessarily see it, pain can seem invisible. We have a harder time feeling <a href="https://doi.org/10.1016/j.jpain.2013.11.002">sympathy or understanding for things that cannot be explained medically</a> with medical tests or X-rays.</p>
<h2>How to become an ally</h2>
<p>So, despite the many explanations offered by patients, they often have to deal with prejudices from health professionals, their entourage or the general population. Many people living with chronic pain feel that their pain is not understood by their friends, family, employers or even their health-care professionals, which adds to their feelings of helplessness, sadness and anger. In addition to dealing with the difficulties that chronic pain brings, these comments place an inestimable burden on sufferers. </p>
<p>Francine, who has been living with chronic pain for 15 years, regularly receives these types of comments from her family and friends:</p>
<blockquote>
<p>Well, you’ve only been walking for 10 minutes, you can do more. Just try harder.</p>
</blockquote>
<p>Sylvie, who has lived with chronic pain for 17 years, has to deal with her doctor’s comments:</p>
<blockquote>
<p>“You are the only patient I have not been able to relieve with cortisone shots in 40 years, so perhaps you should consult a psychologist instead.</p>
</blockquote>
<p>These phrases, which can sound harmless to some, are often loaded with meaning for those who hear them on a daily basis. Accepting chronic pain as a disease is an important and difficult step. It should not be coupled with such pejorative comments.</p>
<p>Without being experts in the field, we can all play a role, in one way or another, in the lives of these people. Offering an active and understanding ear, not making quick judgments and acknowledging their condition is already a huge step in the right direction.</p>
<p>Support and communication with those around you are elements that should not be neglected and can certainly make a positive difference.</p>
<p><em>This article was written in collaboration with Sylvie Beaudoin and Christian Bertrand, patient partners.</em></p><img src="https://counter.theconversation.com/content/189288/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marimée Godbout-Parent has received funding from the Canadian Institutes of Health Research (CIHR).</span></em></p>Although chronic pain is recognized by scientists as a disease in its own right, it remains largely under-recognized, under-diagnosed and, above all, associated with numerous prejudices.Marimée Godbout-Parent, Étudiante au doctorat recherche en sciences de la santé, Université du Québec en Abitibi-Témiscamingue (UQAT)Licensed as Creative Commons – attribution, no derivatives.