The “dull and rusty” science of pain: an interview with Paul Ingraham

Paul Ingraham publishes, an evidence-based site about the surprisingly weird science of aches, pains, and injuries. (Full disclosure, some of it is behind a paywall, though most is not.) Long a fan of his work — I cited and quoted him in one of my Upshot pieces — I caught up with him over email for an interview about what he does and how he does it.

Austin: I’ve personally benefited from your work and am impressed with your ability to write entertainingly while adhering to the evidence. Where did your style come from? How did you hone your craft?

Paul: My craft wasn’t so much “honed” as thrown into a volcano, melted down, and ejected at high velocity. In 2000 I was still an artsy flake, a failed novelist dabbling in essays about health science as a sideshow to my new day job as a massage therapist. But then I got more of an audience than I was ready for, and suddenly my inbox was stuffed with every kind of feedback: gushing fan mail, threats and harassment, and indulgent notes from true experts politely insisting on repairs and upgrades.

I worked myself near to death in a mad scramble to level-up as a science writer. Working with real patients brought me down to earth, taught me some respect for the subject matter. I was horrified by what people were enduring, and my sideshow turned into a mission with real gravitas.

But I clung to my dad jokes, memes, sci-fi references, and passion for good prose. It was always a simple formula: try to have fun taking pain seriously.

From the science, what are the top few things people get wrong about pain? What do we do or believe about the “right” way to limit or relieve it that is actually not helpful?

Pain is weirder than people realize, even in seemingly simple “mechanical” problems like runner’s knee or frozen shoulder. The nervous system is volatile, glitchy, prone to false alarms. There can be huge disconnects between pain and what’s actually going on in the tissues. The mind plays a surprisingly large role — as you’ve written about — and yet not large enough that we can just think our way out of pain.

And yet pain is also an amazingly reliable indicator that something is wrong. Biology is destiny, and a lot of puzzling pain has obscure medical causes, many of them extremely hard to diagnose. For every straightforward cause of pain, there are a dozen that are much trickier.

I also wish people understood that most treatments and therapies don’t work, because the pain system has such deep roots in us that it is nearly impossible to “hack.” Killing pain is like trying to kill a parasite without killing the host. Pain treatments and therapies are tragically underwhelming across the board — almost everything works well enough to inspire legions of fans, because any strong sensory experience, combined with a bit of well-rationalized optimism, can convince the brain to mute the alarm for a while… without actually fixing anything. These sensation-enhanced placebos have spawned many remedies that seem to work better than they actually do, and so the world of pain treatment is cluttered with quackery and fads that waste time and money at the least, and risk harm at the worst. 

“Caveat emptor” isn’t really an adequate warning. Cynicism and pessimism are sadly justified.

A few other evidence-based things I try to teach people about: slipped discs are often painless, “fibromyalgia” explains nothing, self-treatment of muscle pain is one of just a handful of legit rays of hope, systemic inflammation is actually kind of a big deal, the importance of posture and stretching are almost comically overrated, and many common orthopedic surgeries are ineffective.

With so much untrustworthy pain pseudoscience out there, who should we trust? Who are your pain science heroes? Who has done the greatest work? What are your revered studies?

Trust the doubters. The field is polarized: hype and myths are mostly either being busted or perpetuated, so the absence of obvious skepticism and citing the science is a red flag.

Some bloggers that stand out: Lars Avemerie, Todd Hargrove, Greg Lehman, Dr. Bronnie Thompson, Adam Meakins, Nick Ng, Dr. Jen Gunter. For runners and athletes particularly, read Alex Hutchinson, Mike Matthews, and James Krieger. Gina Kolata and Gretchen Reynolds both do great work here on Some noteworthy social media accounts: Dr. Derek Griffin, Dr. Jim Eubanks, David Poulter. For the substantial overlap between pain and nutrition, see Stephen Guynet’s blog, and is a great encyclopedic resource.

For general public education on pain, see The Pain Toolkit, Pain BC, and Pain Revolution. The San Diego Pain Summit is not only a great conference for clinicians (2020’s coming up in 20 days), but they also publish their presentations.

Dr. Lorimer Moseley is a researcher and my biggest influence in the world of pain science. If I had to do his work the injustice of extreme simplification: pain is a mechanism for threat detection, not damage reporting, and understanding pain can ease the perception of threat.  His books are a good place to start.

I also owe a lot to more general medical experts and skeptics — they aren’t pain experts, but neither am I. They are experts in critical analysis of medical claims. Drs. Steven Novella, David Gorski, and the rest of the editorial team at, all taught me how to think about science and medicine, and for that I owe them my career.  QuackWatch and Dr. Edzard Ernst’s blog have also been invaluable to me over the years.

What is on the cutting edge of pain science? Are there any promising things on the horizon that we might later consider breakthroughs?

The cutting edge of pain science is dull and rusty — there’s just too much that we still don’t know. There are always headlines about potential breakthroughs, but they all remind me of news about battery tech: there are always major caveats. “Did we mention this only works in a vacuum?”

But here are a few candidates for greatness that haven’t disappointed us yet.

Transcranial magnetic and deep brain stimulation — tickling the nervous system with electromagnetic forces — is weirdly promising for certain kinds of chronic pain patients.

Regenerative medicine — rapid healing, like Wolverine — will probably get us somewhere eventually; we know it’s possible, thanks to salamanders. Early efforts like platelet-rich plasma, and cell implantation in cartilage have all been weak sauce so far, but I suspect they were just premature.

Moseley’s approach — “Explain Pain”— has not been properly tested yet, but it comes straight out of the research, has great plausibility, and it’s quite practical. Someday it may be established as a major innovation, and many people already see it that way.

A quirky one I’d like to plug, because I’ve written about it recently: treating pain like a conditioned behaviour. This is mostly still just a hypothesis, but it’s a fascinating one that I will be following.

So there are some rays of hope, but mostly we’re destined for more disappointments, because treating pain is not just a matter of complexity: it’s really difficult in principle.

Pain is like cancer: it’s not one thing. There are many different paths to pain, and no one approach can possibly deal with them all. And we’ve learned that the brain’s role is so potent (top-down modulation) that people can essentially “hallucinate” pain no matter what’s going on in their bodies. And we know that anything that can actually suppress pain is tragically likely to suppress our minds as well, and/or force biological adaptation and dependency.

For most patients, the boring basics are still the best we’ve got, especially general health and fitness: reducing systemic vulnerability to chronic pain by being as fit and healthy as possible is probably the closest thing we have to good one-size-fits-all advice for pain patients. For injury rehab, load management is the simple-but-not-easy art of letting things calm down enough and then building them back up again — we can recover from almost anything by baby steps back to normal activity levels.

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