Serendipity (my article on BJSM)

The term serendipity indicates the good fortune of making happy discoveries by chance and, also, finding something that is not sought and unforeseen while you was looking for something else. The term was coined by Horace Walpole in the 18th century and therefore it falls within the category of "author's words".

Serendipity also indicates a typical element of scientific research, when important discoveries occur by chance, while one was searching for something else. In every discovery, as in real life, there is some element of randomness: if the researcher knew exactly what he is looking for, he would not need to look for it, because it would be enough for him to have a confirmation of a reality which he knew already exists.

My life has been progressing this way lately.

I'm not getting things in life, I'm doing something. Well, I'm doing a lot. But I'm making happy discoveries by pure chance. I am following the flow and beautiful things happen.

One of the paper boats I built in the last few months and trusted to the current is an article, which was published in the British Journal of Sports Medicine (BJSM), with the harmless title: Should you first care your ignorance, healthcare professionals? (you can read it by clicking here).

This article was born as a game, as a bet that I would have lost. But no. It has been published.

This article isfor all the people with persistent pain , beated by the genetics and ignorance of those who condemn them to existences that, today, are meaningless calvaries.

This article is for all health professionals looking to make a difference in their daily work, to change our lives, in a world of unprepared who are reputed themselves to be great clinicians and who are not: their ignorance tells us they are not.

This article is not just like any article published in any magazine. It is in the British Journal of Sports Medicine (BJSM): the magazine with the highest impact factor in the world in sports medicine.

This article is peer reviewed. Peer review is a critical part of the functioning of the scientific community, quality control and the self-corrective nature of Science.

All that is written in this article, the incapacity to treat chronic pain, which made me live a tremendous existence for twenty-five years, the discovery of the latest scientific evidence to manage persistent pain, the importance of movement, the uselessness of opiates and anti-inflammatories, the fundamental role of self-efficacy, the pain that is nowhere to be seen, the anger towards a class of health professionals that does not update knowledge, despite the fact that science is evolving ... is peer-reviewed.

So somehow,my story, stops being just a story and just mine. It becomes a weapon to silence fools. Not just for me, but for all patients like me, with an experience like mine. And for all health professionals who deeply believe in the revolutionary change that Science is laboriously bringing to the treatment of persistent pain.

This article is really for those who brought me here, building legs, nerves, knowledge, heart. The lists are useless. Those who are in my heart, they know.

At the links below you can find two Italian translations of the article.

The pill for persistent pain does not exist

I never talk about drugs. It is a choice that arises from the belief that it is not up to me to do so, in addition to the awareness that drugs are nothing more than a small piece of a great puzzle: those who only place hope in drugs are destined to remain disappointed.
Moreover, the temptation to DIY, especially if you are tired of wandering from one doctor to another, can be high.

But, lately, I am often asked about my medications (no, I will never give you the name). So I think I should spend a few words on it.

The goal, when prescribing pain-modifying drugs, is to enable you to achieve optimal conditions to improve physical function, mood, sleep and ability to manage pain. The name“painkiller”, when it comes to persistent pain, therefore, is a bit misleading.

It is very important to identify the type (or types) of persistent pain you are suffering from (nociceptive, neuropathic, nociplastic), in order for you to be prescribed an effective drug. Otherwise, it is impossible for the drugs to be effective. Indeed, they do you more harm than good. They do not help you with pain and harm your body unnecessarily.

To alleviate a painful manifestation, the use of painkillers is almost taken for granted. It shouldn't be though, if the pain is neuropathic or nociplastic (if you don't understand much about these two terms, I suggest you to read here ). In fact, potentially, the drugs that act on the central nervous system are the proper treatment option for "pain system dysfunctions". These drugs are antiepileptics and antidepressants. The name does not count. What counts is the fact that these drugs are able to interfere with the pain circuit: nobody is epileptic, nobody is depressed, simply, given at low doses, these medications can help to "lower the volume of pain". These drugs have side effects, at least at the beginning of treatment, of which a person must be aware, and they cannot be taken "once in a while". They are therapies, not headache pills. So you need to talk to a doctor who knows not only pain therapy, but the mechanisms of central sensitization.

I emphasize, in case there is a need, that these drugs are not opiates (it is easy to think pain therapy = opiates). Opiates are well known to be ineffective or even harmful for chronic pain. It may also seem us a cool thing to be prescribed with opiates, because maybe at last we feel recognized ("Oh, in the end a POWERFUL drug"). Eww. No. In addition to the development of addiction (so sorry for this pun), exists opiate-induced hyperalgesia, which is defined as a state of nociceptive sensitization, caused by exposure to these drugs. The condition is characterized by a paradoxical response, whereby a patient receiving opiates for pain treatment, may become more sensitive to certain painful stimuli.

And ... What about weed? Uh, weed. Mainstream. In February 2018, the "Canadian Family Physician" magazine published a systematic review of studies evaluating the use of medical cannabinoids. After identifying 1085 articles and keeping 31 relevant publications, the authors came to the following conclusions: there is reasonable evidence to support the use of cannabinoids for the treatment of nausea and vomiting associated with chemotherapy; these products could improve spasticity, particularly in multiple sclerosis. It is uncertain whether cannabinoids are capable of relieving pain, if they do they only relieve neuropathic pain (with modest benefits). However, negative effects (sedation, confusion, psychosis, tinnitus, distorted vision, ataxia, aphasia, dysphasia, memory disorders, psychiatric disorders, diarrhea, dry mouth ...) often occur, to the point that the authors have indicated that the benefits expected must be very high before considering the use of these products.

Pain is complex. Pain is difficult to explain. Medications can help. But don't lose the overview. The goal of a drug, when it comes to persistent pain, is to help you reach optimal conditions to improve physical function, mood, sleep and the ability to manage pain. Self-efficacy is always what you need to have in mind. Find people who can lend you a hand and help you be the real protagonist of your journey to healing. Persistent pain asks us to change our looks. And in these new looks we can find real solutions.

Krebs EE, Gravely A, Nugent S, et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar;319(9):872–882. PubMed #29509867
A Comprehensive Review of Opioid-Induced Hyperalgesia by Marion Lee, Sanford Silverman, Hans Hansen, Vikram Patel, and Laxmaiah Manchikanti, on Pain Physician 2011; 14:145-161 • ISSN 1533-3159
The cannabis paradox Roger Ladouceur, MD MSc CCMF(SP) FCMF, ASSOCIATE SCIENTIFIC EDITOR Can Fam Physician. 2018 Feb; 64(2): 86.
Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis Nanna B Finnerup, Nadine Attal, Simon Haroutounian, Ewan McNicol, Ralf Baron, Robert H Dworkin, Ian Gilron, Maija Haanpää, Per Hansson, Troels S Jensen, Peter R Kamerman, Karen Lund, Andrew Moore, Srinivasa N Raja, Andrew S C Rice, Michael Rowbotham, Emily Sena, Philip Siddall, Blair H Smith, Mark Wallace Lancet Neurol. 2015 Feb;14(2):162-73. doi: 10.1016/S1474-4422(14)70251-0. Epub 2015 Jan 7. PubMed# 25575710

The most important things you need to know about vulvodynia (even if you are a man)

I love Sex and the City. Actually, I never wanted to watch it for years, because it seemed rough and vulgar, but once I did, I fell in love with it. And, in the end, when the series ended, with Carrie walking fresh, happy and proud, bouncing on her heels and on "You've Got the Love" by Florence + the Machine for the sidewalks of NY, I had, and I still have, the feeling that an era was over.

Sex and the City has marked a small revolution, perhaps it will have brought a watered-down feminist instance but. thanks to Sex and the City, women now have a language to talk about their sexual experiences, their friendships, their stories and idiosyncrasies.

Of course, attempts at post-feminist emancipation always remain confined to a world that is ultimately "feminine" and heterosexual, but not too much. In short, I love it. Period. It was a socio-cultural phenomenon that cannot be ignored.

And yet there is one thing I don't forgive in Sex and the City . Season XNUMX, episode XNUMX. Do you remember that certain moment when Charlotte tells her friends that she was diagnosed with vulvodynia and that her vagina is "depressed?" Depressed. The vagina is depressed. The dullest explanation I’ve ever heard . I also went to listen to the original audio, to make sure there were no "poetic licenses" in the translation. No. The vagina is depressed, both for Italians and English speakers.

Fine. My personal experience with chronic vulvar pain, because yes, I had that too, is quite descriptive of the situation. First of all, speaking so deliberately of my modesty, I am actually breaking the first taboo because yes, we don't talk about it, we don't have to talk about it. So my mother, as a good feminist, I think she did some damage, making me so shameless about it.

We live in a somewhat phallocentric society . From a quick search, I notice that the "market" of erectile dysfunction (the only male medical condition with which it seemed reasonable to create a comparison) is saturated, with new studies being published continuously: the references on PubMed are XNUMX, collapsing at XNUMX on the theme "vulvodynia". I agree if you object that, among the papers I mention, there are certainly also low quality articles, but you will agree that, even if you want to make a skim and keeping only those of high quality, there is proportionally no history.

Vagina either doesn't care (scientifically speaking) or is scary. And this complicates things. It's strange, considering that the 16% of the US female population encounters vulvodynia in their lives. If we extend statistics to the rest of the world, the problem is remarkable.

An American study of XNUMX titled "The girl who cried pain: a bias against women in the treatment of pain" showed that, despite the fact that women live pain more frequently than men in their daily lives, men receive better treatment for their painful symptoms . A chronic disease of any kind already has a stigma, but this is worsened if the condition is invisible, explains the UK Vulval Pain Society website. And pain is the only manifestation of vulvodynia.

Imagine therefore a chronic painful disease, without an apparent organic cause, applied to a woman, to the most representative anatomical part of femininity, and you will have created the perfect storm.

I know vulvodynia. It destroyed my existence, made me lose jobs, let me discover the benziodiazepines and self-harm. And, frankly, I never understood anything of it, except that the symptoms, which I had learned to control with breathing and biofeedback, are among the ones have disappeared since I started my treatment for central sensitization.


Depressed vagina, depressed vagina ... my dear Charlotte, you miss a bit of definition. Not only is our friend V. depressed because she cannot perform her sexual functions, but she is also deeply saddened. From an emotional and physical point of view. Burning pain, often constant. This is what patients who have had the misfortune of knowing vulvodynia report.

In XNUMX the Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia reported the following definition: localized pain (clitoral or labia minora) or generalized, provoked or spontaneous, with primary or secondary origin (recurrent candidiasis), constant or intermittent (menstrual cycles).

Vulvodynia impacts more or less with the normal course of patients' daily life and this depends on its characteristics and how it can be "subjectively debilitating". After all, pain is a projection of our central nervous system and it is up to the individual to determine the intensity or not.

By grace, pain remains pain and a blowtorch constantly present on our most precious treasure, and it affects our lives, of course it does . It affects the perception of our body, how we conduct our lives and how, inevitably, we live our sexual sphere.

"Come on, after all it's just a bit of inflammation, put some cream on, you will surely get irritated with those super tight jeans ... Let's use a little lube honey, you're just a little tired and stressed." Aha, yes, fairy tales.

Vulvodynia is a neuropathic pain. No one is crazy, none is hysterical. The central nervous system changes, becomes sensitive, becomes constantly touchy, that's it.

The damage can be located anywhere in the nervous system: in the peripheral system, in the spinal or supraspinal system, in the brain.

The explanation is "simple": the nervous mechanisms that modulate the sensation of pain are confused and can send the information nociception to the brain in an amplified way; in the same way the brain "can cry wolf" just because something is working too much and too often. Clinically, neuropathic pain is characterized by two abnormal sensory processes, called hyperalgesia and allodynia. In the first case we mean an amplified response to a painful stimulus which is normal in itself; in the second we mean a change in the perception of the stimulus from tactile to "painful burning". It is not a mirage, after all.

Fortunately, these mechanisms begin to be chewed by most: now we consider psychosexual factors a direct consequence of vulvodynia rather than the cause.

The interaction between biological, predisposing, precipitating and maintenance factors, which contribute to the organic and neurogenic damage of the vulva, can interact with psychogenic factors, which always have a neurochemical correlation. Neuropathic pain is basically a clinical diagnosis that needs to be confirmed by reproducible tests or diagnostic tests (to make it short: we must "see pain somewhere" in a diagnostic exam).

It often happens in the studio that patients come with a sort of personal encyclopedia. The famous "doctor shopping", but no one has managed to find something that could be the source of pain: folders on medical files, all negative. The patient is desperate, suffers, but "has nothing", according to the tests. It happens, very often. Until some time ago we were amazed, displaced and frustrated. Luckily, in the XNUMX those great geniuses of the IASP - International Association for the Study of Pain have found the need to introduce a third point of clarification for those who have "nothing" (nothing to be found or to be seen in a laboratory test ). Nociplastic pain. I quote: pain that emerges from an altered nociception without injury or threat of a tissue that may be the cause of activation of peripheral nociceptors or evident injury to the somatosensory system that may cause pain.In practice, there are people who feel "spontaneously". In this case, especially in this case, the psychosocial component plays a fundamental role as an additional activator of the algogenic process by activating the circuit of the dog chasing his own tail.

Rosemary Basano has conceptualized a model that explains, in a circular manner, the sexual functioning of a woman. The context and the mental state are the most important elements of the female sexual cycle. The interlocking rings of this chain are also sexual stimuli and finally emotional and physical satisfaction (orgasm). The mental state of a woman with persistent vulvar pain or a dyspareunia will certainly not be predisposing. Let us consider that we are facing a woman with a superfine mental strength, one of those who is not discouraged: the coital pain due to dyspareunia interferes with the various aspects of sexual function. It directly inhibits vaginal lubrication, causing excitation difficulties with vaginal dryness: orgasmic difficulty, frustration, dissatisfaction, secondary loss of sexual desire and mental excitement with consequent avoidance of relationships.

When the symptom immediately manifests itself as vulvar pain, it is associated primarily with an inflammation of the vaginal mucosa. This then determines the defensive contraction of the levator ani muscles (main components of the pelvic floor) and, finally, the proliferation of the pain fibers. When instead, on intact vaginal muscosa, the starting symptom is the pain during sexual intercourse, the first consequence is the defensive contraction of the levator ani muscles, followed by the blockage of the lubrication, microabrasions by penetration and proliferation of nerve fibers of pain with vulvodynia finally neuropathic. (Graziottin et al. 2011).

Doctor, what can I do?

Natalie O.Rosen in her review sought to investigate, basing on existing literature, what could be the best treatment for vulvodynia. Her conclusion, which among other things also supports the Fourth International Consultation on Sexual Medicine, points out that the best treatment options are: psychological interventions (no, not because someone is crazy, but to learn how to manage pain in everyday life), pelvic floor physiotherapy, vestibulectomy (for the provoked vestibulodynia).Pharmacological treatments can be beneficial and include antinociceptive agents, anti-inflammatory agents, neuromodulators, muscle relaxants.

As mentioned above, there is a clear link between vulvodynia and pelvic floor muscle dysfunctions, which can be translated into hypertonicity, lack of strength and control. The goal of pelvic floor rehabilitation is to restore functionality to muscles and tissues, lower neural tension, improve sexual function.

Manual pelvic floor therapy includes a wide variety of techniques such as stretching, massage and trigger point treatment by acting directly on the area, neuromodulating the information from the periphery to the central nervous system. We are going to treat the central nervous system, indirectly.

Retrospective studies have reported significant improvements in referred pain, in dyspareunia, in sexual functions after the application of TENS: a current that is able to close the "gates" at the medullary level that send the altered information of pain to the central nervous system.

Rehabilitation yes, drugs perhaps, therapeutic exercise? The low-load therapeutic exercise, adapted to the individual, has basically the same effect as the neuromodulatory drugs. Exercise makes our body produce good stuff, stimulating it, keeping it alive. Among other things, let's not forget that patients suffering from vulvodynia may be subject to fibromyalgia and other pathologies that deal with chronic pain.

Rehabilitation yes, drugs perhaps, therapeutic exercise yes and a lot of awareness.


Unfortunately, scientific information, even among doctors, is struggling to spread and the lives of patients suffering from vulvodynia are often an odyssey from one specialist to another, from one therapy to another without any result. If, after treatment, as it happens, because it is not specific to the problem, the symptoms remain, the patient is told that she has nothing and often to go to the psychologist. The diagnosis, therefore, almost always becomes that of psychosomatic illness. Unfortunately it is a rather widespread situation and it often happens that patients find themselves without a cure and with the label of "imaginary invalid". However, some studies point out that the psychiatric profile of women with vulvodynia is not different from that of women with other vulvar disorders.

So we return to one of our usual discourses. There must be a greater awareness of the condition both among health professionals and the general public. Physicians should be better trained to recognize and diagnose vulvodynia to know what treatments to offer, but also how to explain patients their condition.

Perhaps the only accuracy that Sex and the City offers, is when Charlotte's friends respond to her "Vulvo-what?" while revealing her diagnosis. This reaction is too common among ordinary people and even among health professionals. As always, fortunately, there is scientific research, but there is the usual disconnect between research and practice.

Maybe Sex and the City didn't really fail miserably. It did it in trivializing the serious and complicated nature of this condition, but it had the merit, at least, of making people talk about the problem, after almost twenty years (sigh!) from that episode.

This article is not one's all me. Half of it was written by Carla Sforza, who helped me make sense of a big black hole in my life. She is one of the "beautiful discoveries" that "Le Stelline" brought, and for which I will never be grateful enough. Carla is a freelance physiotherapist, manual therapist, specializing in rehabilitation of the pelvic floor in female urinary incontinence and chronic pelvic pain. You can find her on Facebook as Fisioelle.


"The girl who cried pain: a bias against women in the treatment of pain" by Hoffmann DE, Tarzian AJ. on The Journal of Law, Medicine and Ethics 2001 Spring; 29 (1): 13-27 PubMed # 11521267

2015 ISSVD, ISSWSH and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia by Bornstein J1, Goldstein AT, Stockdale CK, Bergeron S, Pukall C, Zolnoun D, ​​Coady D on Obstet Gynecol. 2016 Apr; 127 (4): 745-5 PubMed #27008217

Fenella Wojnarowska Richard Mayou, Sue Simkin, Alex Day on the Journal of the European Academy of Dermatology and Venereology, July 2006

Graziottin A, Murina F. Vulvodynia diagnosis and treatment strategies. Springer- Verlag Italy 2011

Rosen NO, Dawson SJ, Brooks M, Kellogg-Spadt S. Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches. Drugs. 2019 Apr; 79 (5): 483-493. doi: 10.1007 / s40265-019-01085-1. PubMed PMID: 30847806.

Kinesiophobia state of mind

Kinesiophobia State of Mind.

Once yes. Phobia. Fear of movement. Chronic fear of movement. I've always had it. From what memory I have.

Kinesiophobia is defined as excessive, irrational and debilitating fear of physical movement and activity, resulting from a feeling of vulnerability due to a painful injury or repeated injuries. Here it is. I have always had motor difficulties (the nuns did not help in kindergarten), who have done nothing but get worse at school, where my efforts did not matter to anyone, in fact: I found myself overwhelmed by a flow of kids, whose skills motor skills were certainly superior to mine and I was asked to adapt to their standard, without having the means, with catastrophic results. So for me, moving and hurting myself was the norm. I started having the fear of physical education classes, during which, in junior high, I remedied the whiplash injury that caused the lesion that causes the occipital neuralgia, I broke a couple of flexor tendons of the fingers and other various figures of 💩 that I'm not telling (not to mention the apocalyptic fall that paved the way for persistent pain, but that was accidental).

I believe there is little wonder that it has become kinesiophobic. Somehow, my body has always been a traitor. It was normal for me to choose the brain. It was certainly more reliable.

Obviously, over the years, my kinesiophobia has nurtured and made strong of "don't move", which the various health professionals have offered me. I was happy that I was told not to move. The fact is that kinesiophobia is related to chronic pain. Understanding this relationship can be difficult, but it is important to address the "dysfunctions" that can "cause the pain cycle". To sum up, the belief that something is wrong with our body, and the belief that avoiding exercise will prevent an increase in pain, lead to a vicious circle that involves an avoidance of movement or any activity that could (could, in theory, according to us) cause pain or injury. Over time, the inactivity that results from this fear leads to psychophysical consequences such as muscle atrophy, loss of mobility and an altered response to painful stimuli and behavioral changes, which can contribute to perpetuate pain. In short, a mess: we trap ourselves (unknowingly) even better in the problem.

Immersed in my kinesiophobia, when Luca showed up saying that I had to move to manage the pain, I thought he was crazy (sorry). Because it would have hurt, because I was not able. And it didn't happen that way. What happened was that in my journey I had people who welcomed me. They listened to my fears and, one kg after another, they helped me make it.

So when I mirror myself, with a barbell on my shoulders, and I see all the intelligence of my body, which just needed its time, not to be overwhelmed by the flow of "others", I don't feel simply freed from pain, but also from fear and insecurity. And I firmly believe that the bit of self-esteem I managed to recover has passed and I pass through the instrument that I felt least congenial: my body.

My body, which I look more and more astonished.

Butler DS, Moseley GL. Explain pain. Adelaide: Noigroup Publications; 2015
Crombez G, Vlaeyen JW, Heuts PH, Lysens R. Pain-related fear is more disabling than pain itself: evidence on the role of pain-related fear in chronic back pain disability. Pain 1999; 80 (1): 329 – 339. doi: 10.1016 / 0304-s3959 (98) 00229-2.
Lethem J, Slade P, Troup J, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception — I. Behavior Research and Therapy 1983; 21 (4): 401 – 408. doi: 10.1016 / 0005-7967 (83) 90009-8.
Neblett R, Hartzell M, Mayer T, Bradford E, Gatchel R. Establishing clinically meaningful levels for the Tampa Scale for Kinesiophobia (TSK-13). Eur J Pain European Journal of Pain 2015; 20 (5): 1 – 10. doi: 10.1002 / ejp.795.

In search of the lost symptom

"The drug removes the symptom, but it does not help to deal with what has led to being sick. Psychotherapy removes the symptom and allows us to face the difficulties that led to the development of the symptom ".


Calm. Let's keep our heads. As a basic assumption, it can work.

Psychotherapy has led to a demand for renewal in relation to a tendentially mechanistic vision, in some way functionalistic, of the human being. However, we cannot consider psychotherapy a panacea for all ills or, at least, not in the case of persistent pain. If psychotherapy has changed the view of the human being, which therefore is not a machine, it seems to have jammed on one of its fundamental premises. Pain is considered as an expression of dissociation from emotional trauma: it seems to be an axiom. But is it really an axiom? Persistent pain challenges it, in a scientific way.

Although there are predictive psychosocial factors (emotional trauma, adverse socio-family conditions ...), these are not a sufficient condition for the development of persistent pain (not all those who have persistent pain, have experienced such conditions): pain necessarily has a demonstrable and verifiable biological basis (including nociplastic pain, for which structural and functional cortical changes are appreciable - the famous pain "which is nowhere to be seen").

If pain is a problem on an organic basis, it is not human to think of treating it with exhausting psychotherapy sessions in search of lost trauma, which may not exist (and often does not exist). Rather, it would be useful to renounce the premise pain = dissociation and stop considering people with persistent pain as sick people: they have a disease, they are not their disease, provided that persistent pain is a disease, rather than a (psycho) physical condition.

Scientifically, neurosciences question the premises of psychotherapy. A person with persistent pain is not a sick person, he is a person who lives a (psycho) physical condition, but he is not to be identified with his problem, with his difficulty, with his painful condition, he is a person who needs to be treated, but not in medical terms: he needs to be accepted, tout court. The aim of “cure medically intended” is to lead to the condition prior to that of the disease: it is often not possible. Psychotherapy, accepted all these assumptions, should be genuinely open to these new demands.

The Science of Pain, is a new science, which looks at an ancient problem with new eyes. It is not possible to think of finding innovative solutions while remaining anchored to old prejudices. Psychotherapy, which at the dawn of the twentieth century became the bearer of a revolution, has the possibility of renewing itself by playing a new and very important role, giving people with persistent pain different looks and alternative tools to deal with their own experiences in a constructive and effective way , detaching itself from the old vision of which we have spoken that, in this case, demonstrates its ineffectiveness.

In the case of persistent pain, intervention on the symptom is not useful, because we act with the idea that it is the manifestation of something, of the famous "repressed trauma", while pain is not the symptom, but the manifestation: if we enter this perspective we can try to understand how it affects the life of those who live with it constantly and therefore it becomes possible to work at different levels on pain and its manifestations, disrupting the idea that there is something to cure, to try rather to understand how it is possible to increase self-efficacy and live well with pain.


(We chose to talk about psychotherapy, not psychology, because it intervenes directly on the epistemological constructs of the personality and on the functioning of the persons themselves).


Article written with Andrea Ghirelli, trusted friend, educator, family mediator, systemic relational counselor.


Chronic pain epidemiology - where do lifestyle factors fit in? by Oliver van Hecke, corresponding author Nicola Torrance, and Blair H Smith Br J Pain. 2013 Nov; 7 (4): 209 – 217. PMC4590163

A Broad Consideration of Risk Factors in Pediatric Chronic Pain: Where to Go from Here? by Hannah N. McKillop, and Gerard A. Banez2 Children (Basel). 2016 Dec; 3 (4): 38. Published online 2016 Nov 30. doi: 10.3390 / children3040038 PMC5184813

Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and Their Efficiency by Kai McGreevy, MD, Michael M. Bottros, MD, and Srinivasa N. Raja, MD Eur J Pain Suppl. 2011 Nov 11; 5 (2): 365 – 372. PMC3217302

New concepts of pain, by Anne-PriscilleTrouvina SergePerrota on Best Practice & Research Clinical Rheumatology

Bardolino Chiaretto Bentegodi, 2018

Just a (wrong) word

I can seem a cold person, lonely, indifferent and devoid of feelings. Not so: I had to build an armor. Because surviving physical pain has been complicated. So complicated, that sometimes I don't know where I ended up.

It was even more complicated to survive the sense of inadequacy that caused me to fail to heal, despite all my efforts.

Up to about twenty-two, I don't think I was fully aware of the pain. There was, but it wasn't scary. It has started to be so since the summer of 2003, due to the combination of a number of factors, which I can now clearly identify (psychological, social, environmental, biological), but which at that moment completely eluded me.

In that summer, the pain, and a series of absurd symptoms, began to eat everything. I am no longer just talking about musculoskeletal pain and allodynia, but rigidity, sleep disturbances, stubborn headaches, tinnitus, irritable bowel, alterations in the perception of body temperature, tachycardia, allergic symptoms, dizziness, confused head. I felt like a crazy fly in an upside down glass. At that point I, already a loyal customer of countless physiotherapists, started my tours with doctors, who invariably resolved themselves in trips from shrinks or in bankruptcy treatment and consequent iatrogenic damage.

My pain and my "related" symptoms did not go away as planned, not as I expected, and not even as doctors, physiotherapists, osteopaths, chiropractors and shrinks were expecting.

So, at some point, I became the problem. The problem was not the pain, or my symptoms, or the tremendous situation I was in, or the treatments that didn't work. It was not those who treated me that he had insufficient knowledge about the mechanisms of persistent pain. No. I was the problem. And I was told in the face. As if I were hostile to healing.

As human beings, we generally like to think we are prepared and empathetic, but I wonder if we ever really think about the power of words. Because words build worlds. And the ones I heard from health professionals, have shaped my world and my personality.

Looking back, it is no wonder that I was so ashamed of having persistent pain. No wonder I felt guilty. Because it was really done everything possible to make me feel inadequate, not so much incapable of facing the situation as directly responsible for its maintenance. I do not say it was done deliberately, with the intent to harm, but the result is this.

It makes no sense to deny the complexity of pain by offending the patient, yet it is what happened to me. We are people with persistent pain, not bad people, lying, fragile, incapable, uncooperative, irretrievable, condemned to pain "because of us"; we live in terrible situations, we are forced to adapt to a "standard" with which, frankly, no human being would like to confront: I know that I often say, that I am repetitive, it is just that I want to enter into your head well. Living with chronic pain is not normal.

Considering how important language is for those suffering from pain, any health professional should be prohibited from using inappropriate terms, those that end up making us feel weak, guilty (you'll end up in a wheelchair, just learn to live with it, it's the worst that I've ever seen, you only have Lourdes left) or ineffective (the pain doesn't go away because you don't want it to pass, you're like this because of yourself), crazy (you're doing it too big, you can't see anything from exams). The collection can easily be expanded. These words take us away from healing, first of all. Secondly, they are inhuman. And, in our heads of people with persistent pain, they consolidate a world of ineptitude and guilt.

A fundamental task in the psychology of pain is to help people learn to reformulate their inner monologue so that it becomes more realistic and supportive. Being able to grasp and recognize unnecessary or unrealistic impulses is not easy, but this skill is the basis of many successful adaptations to persistent pain. This insight forms the basis of cognitive behavioral therapy (a form of psychotherapy that aims to change useless thinking behaviors), which plays an important role in helping people live with persistent pain. Living with persistent pain, living well with pain, is a fully achievable goal, I know from personal experience. I would add that it is fully achievable in a context where the patient is not regularly skewed by health professionals, which is often the case.

If the patient is to be guided towards a greater awareness, the same must happen for those who take care of him: health professionals should motivate people with persistent pain, offering a language that must be carefully chosen in order to take more care of the patient, not to rub against him.

When a treatment doesn't work, it's human to find someone to blame. I would avoid accusing the patient, I've already said. I would also avoid blaming the clinician (although in this case, I admit, it takes an effort of mercy, I'm biased). Moreover, by accusing each other, we do not have much to gain. Surely a motivated patient is a step closer to success, and a health professional who is aware of his or her limits will know how to motivate a person, respect it, pass on the right information, when to stop and pass the baton, or choose to inquire.

I do not believe that health professionals are evil by nature. I believe that once we assume that the "old way of proceeding" to which we are accustomed is detrimental, just as we seek new ways for patients to help them reformulate their thoughts in order to live well with pain, it must be given greater emphasis on the importance of "communicating well" pain on the part of health care professionals.

If patients wish to be helped, I assume that health care professionals want to help, so if we interpret the patient / health professional relationship as a dialectic and not as a match between opposing teams, we could achieve something good for both categories.

There is hope for everyone.

When chronic pain kills

One of the "interesting" things that happened to me since I began to leave chronic pain behind, was that people started to recognize my illness. People who had denied it for years, when they saw me go to the gym twice a week, run, treat me with "never heard" medicines and literally become another, they started thinking (mostly to understand) that I was "Really sick".

At that point, even the most unexpected, not only began to ask me for information for the friend who suffers or (even) for himself, but also to tell me about those of their acquaintances who, for years, sought help because they suffered from terrible pains and that, in the end, unable to find him anywhere, they decided they had had enough.

I had always thought that chronic pain could ruin a life to the point of suicide. I myself had thought about it, for about thirty seconds, in the summer of 2003, looking at the pavement from the second floor of the house. Now I had some more empirical data, which was not just about me.

Surely it is not pleasant to talk about suicide. It's not a topic to talk to. But generally, problems are not solved by ignoring them.

We, of chronic pain, kill each other. I don't feel like turning a blind eye.

In fact, unless specific underlying pathological conditions exist, chronic pain "in and of itself" does not die. It is possible to develop a predisposition to cardiovascular diseases, probably caused by prolonged anxiety and stress to which those suffering from persistent pain are exposed, but this is a condition that can be managed with appropriate strategies.

Other factors related to increased cardiovascular risk, cancer and lung disease, often also affecting those suffering from chronic pain, are too high a BMI, inactivity, poor nutrition, but they are all factors related to lifestyle, which is affected negative of a series of prejudices on chronic pain (in particular the need to reduce movement, which is deleterious), not to chronic pain in itself: by improving one's lifestyle, one returns to “normal” ranges.

In short, I don't think I have to explain here what it means to live with persistent pain but, to summarize, it means carrying a load of pain that, in the long term, physically and psychologically is simply devastating. First the body is stolen, then the psyche, sometimes the whole. If he eats it. It takes life. Point. And you can get to contemplate suicide.

Suicide rates are more common among people with persistent pain. Generally the risk factors in this population can be conceptualized in terms of two categories. The first includes factors that are not limited to patients with pain, but are associated with suicidal tendencies in general. The second category groups specific risk factors for people with pain. Some of these are difficult or impossible to change, such as the duration of pain, or affected body sites. Others, such as the intensity of pain, the tendency to catastrophism, functional interference, poor self-efficacy, can be improved with appropriate interventions (and this could be considered good news).

Although rarely discussed, suicide in people with chronic pain often occurs. There is no concrete data on how many people with chronic pain die by suicide every year. But there are some assumptions. It is believed that on about 40.000 people who succeed in their suicide attempts every year in the United States, at least from the 10 to the 15% are people suffering from chronic pain. The truth, of course, is diabolically difficult to understand with certainty (I do not want to dwell on dissertations on the subject, but we do not have the data of people who do not leave letters explaining their motivations and it is often not possible to frame opiate overdoses such as intentional acts, etc.).

Because individuals with chronic pain are at least twice as likely to report suicidal behavior or suicide, it is of the utmost importance to identify which risk factors contribute most to increased suicide risk. There is solid evidence that chronic pain itself, regardless of type, is an important independent risk factor for suicide. The only sociodemographic factor found associated with suicide in individuals with chronic pain is related to unemployment and disability. Depressive symptoms, anger problems, harmful habits (such as smoking, alcohol abuse, illicit drugs), adversity in childhood or adulthood and family history of depression or suicidal tendencies have all been identified as general risk factors.

Regarding pain factors, sleep problems, low mood, the concomitant conditions of chronic pain and the most frequent episodes of intermittent pain, they have all been considered predictive factors of suicide. Unexpectedly, the characteristics of pain (eg type, duration, intensity, severity) and physical state do not seem to be related to suicide risk. Psychosocial factors (for example the sense of mental defeat, the tendency to catastrophism, despair) are more significant, associated with suicidal outcomes.

A large number of these factors are susceptible to change through targeted intervention, emphasizing the importance of thoroughly assessing patients with chronic pain at risk of suicide, also incorporating a suicide prevention component in chronic pain management programs.

The sad situation of patients with chronic pain, and their potential link with suicide, will hardly improve until the chronic pain epidemic is really taken seriously, acting really effective strategies that are not based on the prehistoric treatment of the problem .

People living with chronic pain are the reason why increased care funding is needed to manage chronic pain, at all levels, starting with the training of health personnel (and others). The weight of pain often exceeds the human will to live, too often not because research is lacking, but because of a dramatic lack of skills on the part of those who should take charge of the health of patients, who are left to themselves, lives without lives, in which the pain leads to a disintegration of the lived, of the relationships, of the personality, with very serious repercussions, which should no longer be ignored.


When pain kills - chronic pain and chronic diseases by Chris Williams on Body in Mind read it here

The Painful Truth, by Lynn Webster

A Nation in Pain. Chronic Pain and the Risk of Suicide by Judy Foreman on Psychology Today

Chronic pain and suicide risk: A comprehensive review, by Melanie Racine Neuro-Psychopharmacology and Biological Psychiatry PubMed # 28847525

Testing the Interpersonal Theory of Suicide in Chronic Pain by Wilson KG, Heenan A, Kowal J, Henderson PR, McWilliams LA, Castillo D on Clinical Journal of Pain PubMed #27768608

Remission From suicidal Ideation Among Those in Chronic Pain: What Factors Are Associated With Resilience? by Fuller-Thomson E, Kotchapaw LD on The Journal of Pain PubMed # 30979638

Chronic pain does not exist

We constantly hear about cancer, diabetes and heart disease. I think it's good. Not that you love hearing about diseases, of course, but if something is talked about, it means that you are not sweeping it under the rug pretending that it does not exist. Talking about it probably also means more prevention, more research.

Obviously, the perception that results is that cancer, diabetes and heart disease are the great evils of our time. What if I told you that things are not exactly like that? It is estimated that around 1,5 billion people worldwide suffer from chronic pain. It is a huge number, higher than that of cancer, diabetes and heart disease put together. This data is obviously a projection made in the light of some surveys conducted in Europe, the USA and Australia and Asia. It affects at least one adult in five, leaving out children and adolescents. Studies conducted at European level confirm that persistent pain has a significant impact on daily life, sociality and the quality of life of those affected.

Between the middle and the 2 / 3 of those who live with persistent pain, sees their ability to rest normally, move, participate in social activities, drive a car, have a normal sex life diminished. Not to mention that one in four people say that relationships with friends or family members have become less frequent or interrupted. One in three is less able, or completely incapable, to maintain an independent lifestyle. One in five is depressed because of pain. The 17% suffers so much at times that it would like to die. Some really kill themselves, but the study doesn't say how many. The 39% of respondents feel that their pain is not properly managed and that doctors do not consider pain a problem. Chronic pain, not wanting to consider the psychosocial aspect, because for now we assume that we are heartless and the suffering of others does not care about a tube, it has a tremendous economic impact.

Let us reason as if we were Ebeneezer Scrooge: lumbar pain alone is one of the most impactful economic burdens in developed countries. In fact it implies costs for care, for welfare, but also for the absence from work and the drop in performance of those who have to take on the tasks of absent colleagues, loss of earnings for companies and for the patient, decrease in earnings and, therefore, the possibility of spending for those who eventually find themselves in the position of having to support the family forced into inactivity because of chronic pain. Research also shows that those suffering from persistent pain are more at risk of losing their jobs and often cannot work outside the home. In short: we are talking about an apocalyptic problem, with tremendous social and economic implications.

So I think the legitimate question, without using bad words, is: "Why is the global pathological burden of chronic pain underestimated?" I searched for some answers. The answers that are there, when they are found, make one shudder. In this regard, I found a simple but rather interesting document for my hands. A "Fact Sheet", entitled "Unrelieved Pain is a Major Global Healthcare Problem". Persistent pain is not diagnosed and is not treated because it is considered "psychosomatic", fruit of depression (I have already become a pressure cooker) that often afflicts those who suffer from chronic pain, therefore lacking a real organic cause. It is not diagnosed because treatments are considered futile. It is not diagnosed because pain is inevitable. It is not diagnosed because patients are old and have little to live, or are they too small and some still believe that children do not feel pain, or that third-degree burns are pain-free. Primarily, there is still unacceptable ignorance about the subject. And I'm not saying it. The World Health Organization says so. Including the reasons why chronic pain is underestimated, that are fundamentally determined by a series of goat biases (forgive me, I have been kind to this), What are the obstacles to the evaluation and treatment of chronic pain? I have a suspicion, but let's see what the "Fact Sheet" that I have on hand tells us.

The first culprit is, ladies and gentlemen, ignorance above. Lack of knowledge or awareness. This problem does not only concern the poor patient or his family, who may be florists and would have the right not to know a damned persistent pain, but also health professionals, so those who should treat him, the poor patient and who , supposedly, I add, they should at least know more about him. Moreover, we consider that in Europe, one in four patients with moderate or severe pain reports that the attending physician never asked questions about the pain, did not think that he had problems with pain and, in any case, even if he asked for information, he paused briefly and failed to provide a solution. That good news. Although the availability of opioid analgesics to relieve cancer pain has increased even in developing countries, thanks to the efforts of the World Health Organization, cancer pain is not the only severe persistent pain that exists and opiates do not they are the only drugs needed to treat it, so most people with persistent pain remain without adequate drugs worldwide.

And what do you do to change this state of affairs? We educate ourselves. You study, you learn. Such as? Changing university programs, for example. Reading scientific magazines. Going to training courses. Stopping to consider yourself intellectually and morally superior to your patients, because a degree in a medical health profession does not ennoble man.

It's a big problem, I'd say. And it does not seem to me that the World Health Organization and the International Association for the Study of Pain have been very successful.

The Fact Sheet I'm reading is from the 2004. It was carried out on the occasion of the First Global Day Against Pain by the International Association for the Study of Pain - IASP and by the European Federation of Chapters IASP - EFIC, with the co-sponsorship of the World Health Organization. Old news? In terms of time for sure. If we rely on the results, frankly the contents seem to me to be valid.

Something is moving, it's true. But there is still a tremendous disconnect between clinical practice and scientific research. And it is not admissible. We must continue to talk about pain. There is nothing ignoble or whining about it. It would be like not talking about cancer, because it is not dignified or gives us sadness or is not "virile". To me it would seem simply incredibly stupid.


Unrelieved Pain is a Major Global Healthcare Problem, Fact Sheet, IASP - EFIC

The beginning of (my) history

I state, in my defense, that I love my mother madly. She is a brilliant woman, a cross between Alice in Wonderland and Piperita Patty. My mother is an artist. Which means that it has a very refined taste when it comes to flower compositions and watercolor painting or furnishing, but everything that is not figurative art is beyond its interest: the wardrobe, for example. As long as it's your own, there are no particular problems, as far as I'm concerned. But when it comes to my well, it was hard to be twelve and put her into a counterculture militant. When my companions were hiding in bomber of Energie, flared jeans and Kikers, I was condemned to clothes like an intellectual in the grass. They made fun of me for my milk-white skin, they called me "the dullness". No, I don't tan. Never. It is not a quirk. I'm like that. It's called the 1 phototype. If we add to this the wardrobe, we understand how my desire to disappear increases, but becomes more and more an unrealizable desire. I had the gene for being upstream in me, but at twelve I didn't know what to do with it. It was Saturday. I think it was spring. When they left school they started making fun of my skin color. The oversize sweater didn't help me have courage. I had black leggings. Black ballerinas. I don't know what exactly happened. I know that the bully-boss has froze me in front of me, then I fell. The backpack, full of books, with its exorbitant weight, dragged me backwards, and I stayed there, so, on the ground, in the middle of the road, for a time that I can't define, I presume fainted. I don't know what exactly the phrase "see the stars" derives from, which is used to describe being struck by a strong and sudden pain: the fact is that I saw the stars or rather the stars (here they are!). And it wasn't a bright flicker in front of my eyes: I took a walk right in the middle of it, in a dark blue tunnel. And from that day my long and very complicated love story began with chronic pain. Why do I call it love story? Because our relationship has been a long life, mine, and it has been difficult, made of very long moments of mutual misunderstanding, then in some way it has blossomed, when I found the way to speak its language: it may seem delusional, but it's not too much. You will understand by reading. After all, I can't say I hate my past life: it was my life.

When I woke up, after my astral walk (it is the case to say it), there was no one around me anymore: I was alone, lying in the middle of the road and I was suffocating. I remember lifting myself off the ground by pulling my arms out of the rucksack straps, abandoning it there, and walking rattlingly into the arms of a perfect stranger who, somehow, rubbing my back and hugging me, managed to bring me back to life. I did not feel the victim of an act of bullying, in the '92 I had not even heard of it, but only a perfect idiot: a simple, further, living confirmation of my clumsiness.

Here, to me the chronic pain touches from that epic fall, of which, essentially, it has not imported a pipe to anyone. I had fallen. Everyone falls. I played with Barbie and I had atrocious back pain, but they told me they were the pains of growing up. It didn't seem to me that none of my classmates suffered like this, moreover in an area hit by a crazy blow, but I took the explanation for good. In short, it seemed to me that it was my grandmother who had back pain and I certainly didn't have my grandmother's age, but I made the interpretation go well.