Pain is a complex biopsychosocial phenomenon. Given the many factors that impact pain, adequate treatment requires a comprehensive approach – one that considers the cortical, inflammatory, and psychosocial factors that impact it. We consider the entire pain pathway – its molecules, cells, and circuits – and how seemingly unrelated behaviors such as poor sleep habits, can lower pain threshold and tolerance, and if left untreated, can be a barrier to pain management.
Lifestyle behaviors and choices we make every day, directly impact inflammation, immunity, the nervous system, and many other elements integral to the pain experience and healing.
Science Supports Improvements in Musculoskeletal Health Through Lifestyle Medicine Interventions
According to the NIH:
25.3 million American adults suffer from daily pain
23.4 million American adults report a lot of pain
There is an epidemic of pain in the United States. Chronic pain affects up to 30% of the population – more than any other chronic disease.
Let’s review some of the recent scientific evidence showing the impact of specific lifestyle behaviors on musculoskeletal health, pain, and inflammation:
1. Diet
According to 2020 data from the Osteoarthritis Initiative (a study sponsored by the NIH), poor diet is linked to worsening knee osteoarthritis while a better eating pattern is associated with less progression. This is verified both by x-ray findings and reported symptoms.
Diet is also directly related to bone health, impacting bone demineralization, bone fragility, and fractures. Excess body mass may further contribute to bone fragility and fractures, as well as increased risk of gout, osteoarthritis, limited functional capacity, and musculoskeletal strain.
Importantly, certain lifestyle-related disorders, including obesity, are associated with chronic systemic low-grade inflammation. Systemic inflammation can cause local inflammation which results in pain. In fact it has been found that obesity is an independent risk factor for local inflammation. 2
Pain and inflammation are intimately linked. Several studies demonstrate that dietary changes reduce inflammatory markers with a direct impact on pain and inflammation. For example, phytochemicals in fruits and vegetables have been shown to act as antioxidants with an anti-inflammatory effect. 3 Overall, it has been found that an anti-inflammatory diet is associated with less pain, less disability, less depression, and improved quality of life.
2. Physical Activity
Despite the large body of data showing that physical activity promotes a number of health benefits, physical inactivity is highly prevalent and closely associated with premature death and preventable disease. In fact, if inactivity was decreased by 25%, more than 1.3 million deaths world-wide could be averted annually. 4
With respect to musculoskeletal health and pain, there are numerous consistent benefits to physical activity, and risks of inactivity. In addition to strengthening our heart, bones and muscles, exercise has anti-inflammatory benefits, which is significant in the area of pain. In regard to risks, sedentary behavior is independently associated with back pain and joint degeneration. 5
3. Sleep
Sleep is vital for good health. There is a significant interplay between pain and sleep. Insomnia is highly prevalent among individuals with chronic pain. Insomnia is associated with fatigue, poor mood, impaired cognition, anxiety/depression, chronic systemic low grade inflammation, and a lowered threshold and tolerance for pain. It has been found that when sleep is improved, chronic pain sufferers report less pain. 6 & 7
4. Stress
Mental health is also an important factor in chronic pain, and the way that one copes with stress has a demonstrable impact on musculoskeletal health, pain, and functional capacity. Chronic stress has broad multi-system consequences and has a direct impact on immune function and inflammation. It leads to muscular tension which causes pain in the shoulders, neck, back, and other areas. Its impact on inflammation makes one more susceptible to tendonitis and other pain syndromes. Stress also leads to the production of cortisol, which can induce multiple health consequences including bone loss.
Stress can be effectively managed by mind-body techniques that can lead to an opposite phenomenon, initially described by Dr. Herbert Benson as the “relaxation response”. This state leads to a decrease in heart rate, blood pressure, respiratory rate, and exhaled nitric oxide. This impacts inflammation, immune function, and overall wellness. 8
Mind-body interventions also affect the way pain is perceived by directly impacting the way the central nervous system processes it. Mindfulness-based interventions have shown to be effective in the treatment of chronic lower back pain and other chronic pain conditions, decreasing the intensity of pain.9 & 10
5. Toxic Substances
In addition to being very harmful to general health, smoking and second-hand smoke have significant detrimental effects on the musculoskeletal system. Smoking causes bone loss and fractures, delays in healing, increased inflammation, and reduction of pain threshold. It is associated with chronic pain intensity and prevalence, and has been found to aggravate the progression of back pain and arthritis. 11
Quitting smoking improves musculoskeletal health and function by improving cardiovascular and pulmonary functioning, bone health, immune function, and anti-inflammatory response.
6. Social Connection
The effects of social relationships on mental and physical health can be felt experientially, but are also backed by science. As described by psychiatrist Dr. Edward Hallowell, these ties extend beyond just human relationships and include ties with nature, pets, and more. Positive connections are beneficial to the immune, endocrine, and cardiovascular systems.
Conversely, the adverse effects of social isolation are well-documented. For example, a 2016 systematic review article published in Heart found that poor social relationships were associated with a 29% increase in risk of coronary heart disease and a 32% increase in risk of stroke. A review article published in 2004 in Lancet Neurology found protective benefits against dementia and Alzheimer’s disease.
Clearly, lifestyle medicine therapeutic approaches can have a profound effect on health. These methods have been found in many instances to be as good as or better in treating chronic conditions than medications and surgery.
In the area of pain, we have learned that pure biomedical treatments do not work. Unfortunately, the significant increase in interventional procedures, surgeries, and medications have not reduced the prevalence of chronic pain. The error lies in the application of an acute care model to a chronic condition. Our improved understanding of chronic pain has revealed its complex, multidimensional, biopsychosocial nature. There is an undeniable link between lifestyle and health outcomes. Individualized lifestyle modifications based on root causes analysis should be the first line of treatment and provide the groundwork for all other treatment options in the management of chronic pain.
1 Brain K, Burrows TL, Rollo ME, et al. A systematic review and meta-analysis of nutrition interventions for chronic noncancer pain. J Hum Nutr Diet. 2019; 32: 198-225.
2 Shiri R, Viikari-Juntura E, Varonen H, Heliovaara M. Prevalence and determinants of lateral and medial epicondylitis: a population study. Am J Epidemiol. 2006; 164: 1065-74.
3 Zhu F, Du B, Xu B. Anti-inflammatory effects of phytochemicals from fruits, vegetables and food legumes: A Review. Crit Rev Food Sci Nutr 58(8): 1260-1270 24 May, 2018.
4 Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT; Lancet Physical Activity Series Working Group. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012 Jul 21;380(9838):219-29.
5 Hootman JM, Macera CA, Ham SA, Helmick CG, Sniezek JE. Physical activity levels among the general US adult population and in adults with and without arthritis. Arth Rheum. 2003; 49:129-35.
6 Haack M et al., Pain sensitivity and modulation in primary insomnia. Eur J Pain. 2012;16:522-33.
7 Kundermann B, et al. The effect of sleep deprivation on pain. Pain Res Man. 2004;9:25-32.
8 Black DS. Slavich GM. Mindfulness meditation and the immune system: a systematic review of randomized controlled trials. Ann NY Acad Sci. 2016; 1373(1):13-24.
9 Reiner K, Tibi L, Lipsitz JD. Do mindfulness-based interventions reduce pain intensity? A critical review of the literature. Pain Med. 2013 Feb;14(2):230-42.
10 Morone NE, Greco CM, Moore CG, Rollman BL, Lane B, Morrow LA, Glynn NW, Weiner DK. A Mind-Body Program for Older Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA Intern Med. 2016 Mar;176(3):329-37.
11 Abate M et al. Cigarette smoking and musculoskeletal disorders. Musc Lig Tend J. 2013;3:63-9
