A built-in 'off switch' to stop persistent pain
penntoday.upenn.edu195 points by gmays 4 days ago
195 points by gmays 4 days ago
I'd like to give an off switch for pain to every adult. Here you go, just turn it off if you need to. But if someone gave one to me I'd be in trouble, if not dead. When my back pain got severe I may well have killed the messenger, ignored the pain, and not have made the lifestyle changes that eventually gave me relief by fixing the problem. People with congenital insensitivity to pain usually have multiple damaged joints by adolescence. It's not very enviable.
Chronic pain is different. It's a messenger telling you there's something wrong with your back when there's actually nothing wrong with your back. There's something wrong with the messenger.
That is at bare minimum not always the case. I had a couple of degenerative discs in my 30s and that caused chronic pain but it was definitely not the case that nothing was wrong with my back. It just wasn't something fixable, until physicians finally realized it would never heal and just removed the discs and gave me a couple interbody fusions. I'm fully recovered a decade later, but as shitty as the pain was, if there was an off switch, I'd have possibly paralyzed myself putting the spinal cord into a compromised position.
As someone with back pain, what were the lifestyle changes?
I’ve been on a year plus journey with this. My back pain was lower back and every few months I’d “throw out” some part around my shoulder blades and be flat in my back for a day or two. It got pretty bad.
I went to physical therapy for two months because that’s all insurance would pay for. My spine was weak and lacked stability. They had me doing stretches for back mobility and core strengthening. I continued that when insurance ran out and added in a lot of walking and other light weights and calisthenics.
It’s been a long journey and I’m only half way to where I was. The worst part is I did it to myself by becoming sedentary for to many years.
Best of luck for your continued recovery. Keep at it.
I can’t tell you to do this because I don’t know your medical history, but slowly working your way up to medium weight training can also be a game changer. Re: squats, Romanian deadlifts, pull ups, dead hangs.
Deadlifts are what caused my bad back, and also, surprisingly, what fixes it. The difference is that a 120kg deadlift caused it, and a 50kg deadlift fixes it.
Exercise is great, but don't lift too much weight. Prefer more reps instead.
Upper back and neck pain for me. Went to a Phys. Therapist and got a set of exercises. It was largely muscle weakness from bad posture - something many, many people will likely suffer in the coming years thanks to staring at screens on handhelds.
Mine was because I have the posture of a lump of VERY wet clay.
Also, losing weight helped a lot - less to carry around and hold in the right places.
Prolonged sitting deconditions the gluteal muscles, and other muscles often compensate, which can overload them and alter hip/pelvic control. When tissues are strained, the body initiates repair via inflammation—a normal phase of healing. Routine NSAID use can blunt aspects of musculoskeletal healing in some contexts, so it’s worth using judiciously and with clinical guidance. With reduced movement, fascia can lose glide and become stiffer, limiting mobility. Over years, chronic abnormal loading may contribute to osteophytes (joint margins) or enthesophytes (at tendon/ligament insertions). Targeted strengthening, mobility work, and load management from a PT typically help.
What do you mean "in the coming years"? Smartphones have been mainstream for ~15 years now, daily long term computer usage for decades.
Computers have been more in the realm of the younger generations for a long time now, and young people can handle bad posture and other things more easily than the elderly can. I mean we're waiting on them to reach the age where their body can no longer handle it.
My dad had a business installing mainframes when I was young - back when mainframes were still installed in individual businesses, you know. At the time I was a kid, but I know we always had some of the first tech on the block, so I doubt many had tech before me.
I'm reaching the age where I can no longer handle a bad posture - I assume this is going to start getting bigger in the next 5-10 years. I could be wrong, I dunno, but I don't think so.
I recommend McGill's Back Mechanic book, which is an end-user focused distillation of his academic work.
It suggests simple tests to discover exactly where your pain is coming from and then appropriate exercises to mechanically strengthen the right area and a few workarounds to avoid stressing that area in regular life e.g. alternate ways to pick up light items from the floor.
McGillcs big three are three simple exercises that are generally good for those with no patience for ordering a book and intros to them can be found all over YouTube.
Doing heavy barbell squats and deadlifts worked wonders for me. Three sets of five (with appropriate warmup of course).
Eliminated my back pain and led to a bunch of other non obvious life improvements.
There's no need to do them heavy for health purposes. The problem with most back pain is people do nothing. Capping them at around 100kg is probably more than enough and will also prevent other injuries.
The nice thing is that it's _very_ easy to get to a lifting weight that's considered super heavy in normie reckoning, but a warmup weight for folks that lift regularly. In other words, you can get to squatting 50kg/100lb (one 15kg plate on a side) in a couple of months where you won't even think twice about that much weight, but it's still a huge weight to be squatting. Stopping there, and not chasing the gains is a perfectly good way to work your body out on a regular basis.
The absolutely liberating feeling that comes with the noob gains is incredible. Knowing you can lift those weights, safely, without injury, was an incredible experience for me. I topped off at a hair below 100kg squats before life got in the way.
Yes, I'd say anything you can get with noob gains is fair game. By noob gains I mean everything you can get from just increasing the weight a bit every time you hit the gym.
Once you need more complicated programming to make progress, your noob phase is probably over.
For what it's worth, I got up to 170kg backsquats at about 72kg body weight back in the day. The most complicated programming I did was a weekly cycle. ('Texas method'.)
But that was only down to thighs parallel to the ground. Years later I worked more on my flexibility to be able to squat all the way down (but with less weight).
When I turned 50 I started capping my max weights because I was more worried about long-term joint and ligament health than ultimate strength. I no longer lift above two plates (225lbs) for anything, even though that is well below my deadlift, squat, etc.
It's been a couple years, now, and honestly I wish I'd made the change sooner. I haven't lost any functional strength, and my recovery is a lot smoother. Haven't had any injury since, either.
I’m almost 30 and made this change about a year ago.
I now rotate between high rep (sets of 20 rep max) and medium weight weeks (sets of 8-12 reps). My joints haven’t ached in a while and I’ve become much less prone to random muscle tweaks. Mike Isreatel has an excellent intro to high rep training [0]. It produces pumps and mind-muscle connection like nothing else!
I actually went too far into the high rep/volume training direction for several months, but realized I needed to reincorporate medium weight lifts when I started losing a bit of grip strength. I am now super content with my current rotation cycle!
I'm over 50, and I am back chasing the 1,2,3,4 plate standards at a lower bodyweight than when I first achieved it.
The only change I've made is two train only twice a week, rather than three or four times. Thinking of doing the split in Radically Simple Muscle, though, where it is 2 heavy compound lift days per week and a 3rd bodybuilding/machine day.
I think you could put the cap a lot higher than that, depending on the exercise. Strength is like IQ - higher is better.
I admit, though, unless you compete killing yourself for 6 months to go from 250kg deadlift to 252.5kg is probably not worth the effort.
Similar, though I would also add shrugs or reverse flies to get those traps. If I let my traps get weak I get a lot of pain in that region, especially after long periods of sitting
Deadlifts if done right also helps tremendously with improving posture.
For me it was the combination of deadlifts and couch stretch, because I found my hip flexors were fighting to tilt my hips forward. That combination essentially 'cured' any back pain I had. It's not a real cure because if I'm inactive it comes back but so long as I'm moderately active I have no pain
goblin squats helped my persistent lower back pain almost immediately.
Goblet? Or is this something new? Deep goblets are great for opening the ankles and hips/SI area in ways that have helped my back. Some combination of improving mobility in other reasons prevents my back from overcompensating I guess
Daily whole body motion, for me usually in the form of yard work. I am driven to it by the threat of torture, but it works.
2 kids under 4 (and another due next month) fixed my back pain. Turns out that constantly picking up babies and toddlers is the exact amount of exercise my back needed.
Be careful, I'm currently in treatment for a shoulder that has given me significant trouble and I suspect it was due to picking up my (bigger and heavier than average) son. Not that I have hard evidence, but it was pretty much the only frequent physical activity that could strain my shoulders when the problems started, as I didn't exercise apart from long walks.
Not GP but my husband suffered from absolutely debilitating back pain that limited his activities drastically. He went to PT. The fix was consistent exercise and stretching. The cause was muscle weakness and imbalance. He has to maintain it, otherwise the pain starts again.
Aside from resolving the cause, I had to use a foam wedge knee bolster to stabilize me while I slept for an unrelated injury, and I was amazed how much that almost immediately also reduced my lumbar pain.
Swimming 100%. I was injured far enough I had problems even with walking and load bearing activities, but I was able to swim which enabled my recovery.
Lower or upper?
Lower: lose weight, get moving, strengthen hips, glutes and calves.
Upper: lose weight, get moving, strengthen chest, lats, core
Core should be included in lower as well.
I don’t disagree but IME, I got 100x the return from glute work (stabilising my hips) than I did from core work.
Weak glutes are a common symptom from sitting too much and then other muscles around the hips compensate which causes multiple issues with hip tilt and gait.
For upper, I'd highly recommend adding rear delt flys and face pulls at twice the frequency of any chest or shoulder workouts. Most people have overdeveloped front delts and underdeveloped rear delts and that can cause severe imbalances.
Indeed, also lots of over-developed chests which can pull too hard on a back that isn't equally strengthened, causing pain and poor posture
Also for upper (especially if you get neck pain or upper back pain between shoulder blades): Traps (shrugs, reverse fly, and/or face pulls are my preference)
Simply walk.
Walk every morning. Walk every hour (unless sleeping). Walk uphill every day (see documentary on Blue Zones).
But for now: just focus on resisting the urge to tell me why it can’t be done… Like Nike’s slogan: “Just do it”
Good luck, it’s though, and painful but it gets better.
If you can, walking is great for prevention.
With my husband (and probably most people who already already suffering with pain) the pain was too much to walk, and walking was very much counterproductive, so this is bad advise, especially the l "focus on resisting the urge to tell me why it can’t be done" part. It's not the type of pain that you can just power through. He said the pain caused his legs to physically stop working. He had to do PT exercises first and build up to walking.
You might be right.
I wonder if something else might be more viable:
Instead of a simple switch, make it so that people can replace pain with something extremely tedious (but not painful).
There have been a few consequences to my pain tolerance. I grew up with chronic pain and daily recurring severe injuries, the doctors discouraged pain killers because I would become dependent and so I had a slew of paid mediation techniques as a kid and now. I still do not have pain meds, except if the doc has no choice, like I have to go under for an operation.
Perhaps the most counter-intuitive thing is that my body over-reacts because it can't accurately gauge what is happening. Like if I bump a table, my reflexes freak out, because sometimes I bump a table and nothing happens, but other times I bump a table and it's A Really Bad Day.
I think the lack of pain meds can surprise people but I also think maybe I'm not thaaat tolerant, there's just a trend to treat any discomfort with meds. So whilst I am probably more than average tolerance, I think most tap out early and could endure more if they needed to.
> Like if I bump a table, my reflexes freak out
I know exactly what you mean. I have chronic lower back pain and sciatica but mild enough that I can manage it without medication most of the time.
But often, just walking through the house I will bump into a doorway etc and get a sudden spike of pain not from the bump but from my reflexive response.
Sorry to hear about your condition and I hope you can manage it successfully.
You are lucky that lifestyle worked. I had to have surgery, otherwise that tumor (not cancer) would have put me in a wheelchair.
so see your doctor
Its funny, I had some persistent low grade back pain. Specialist gave me medication not to reduce inflammation but just to mask it. Didnt’t realize until got it filled.
It’s the medical equivalent of putting black tape over the “check engine” light.
This is pretty much what modern medicine does 80% of the time. I think that evidence based medicine, however useful the idea was originally, has become a major vector for this. Here’s how it works: choose a symptom of a disorder you want to treat. Find a drug target that you think will reduce the symptom. Apply the drug. Does it reduce the symptom by a statistically significant amount? If so, great! You have “evidence” that the drug “treats” the disorder. Does it cure anything? No, but that’s not the question you asked.
> The drive to look deeper into these neurons grew out of a simple observation Betley and his team made shortly after he joined Penn in 2015—hunger could dampen long-term pain responses. “When it came to chronic, lingering pain, hunger seemed to be more powerful than Advil at reducing pain.”
This in itself is a very interesting observation. I've always been inclined to fast during times of pain and anxiety, and honestly it kind of works? Could well be part of meditative fasting's popularity throughout history.
Yeah I fasted for the first time last year, and it pretty much immediately turned off a pain response due to an overactive immune response
I got the idea from a book, and it worked
When I ate again, it came back, but I was definitely relieved of pain for awhile. Thankfully the whole episode subsided after about 6 weeks, but it was comforting to know that I could turn it off by fasting.
How many hours of not eating does it take to kick in?
For me, it has to be long enough for me to notice the hunger, and then for the hunger to subside. Between that point and lethargy/dizziness is a pretty zen place for me.
(Disclaimer: I am not a doctor, and I have no experience with eating disorders.)
If you think about it, this has evolutionary advantages as well. No time to feel pain when your life itself may be in peril due to starvation. Finding food for sustenance easily supercedes recovery.
Especially if you haven't done this before, you start experiencing very strong hunger about 8-12 hours after your last meal. This is very, very much in advance of any kind of threat to your life or health from starvation. In fact, the sensation of hunger typically dulls after another 12h or so, so that if you make it past 24h of not eating, you'll typically feel less hunger than you did your first night of skipping dinner.
I wonder how many problems are solved in a more common sense way than pills/etc
For example, most headaches I have - drinking a glass of water usually fixes it.
Maybe feed a cold, starve a fever. And now starve lower back pain?
I noticed the same with allergies! In the spring time when my nose runs bad, it always pauses while I eat!
Anyone who's experienced or knows someone who has experienced chronic pain appreciates how desperately the world needs a major breakthrough in this arena. Pain management has evolved, there are steady improvements, but unfortunately a lot of people are effectively left behind and the choice becomes a series of profoundly mind-altering drugs... or profoundly mind-altering pain. The way that pain can erode your personality and your life is hard to express quickly in words, but it's both invisible and endlessly corrosive.
I certainly hope that this or another path of research leads to a new generation of therapies that don't depend on opioids and are more effective than current alternatives.
Yup. Treatment these days for chronic and severe pain amounts to your choice of:
1) Ever escalating doses of NSAIDs / acetaminophen and the associated long term health effects of that.
2) Long term opioid management which will leave you treated like a drug seeker by anyone who isn’t your pain doctor and may or may not also require long term escalation and has its own health concerns and complicates your use of other medications. And god help you if you don’t like your pain doctor because changing them is a whole different world of suspicion and poor treatment.
3) Various physical interventions like nerve ablations or back surgery or steroid injections which come with a host of other risks and also tend to be both expensive and temporary.
I’d love an alternative to gabapentin while accepting that it is what keeps me functional enough to be functional, it is for me a remarkable treatment except for the side effects.
If you can tolerate pregabalin (Lyrica), it's better at masking pain while causing less brain fog
The company I work at does spinal cord stimulation for chronic pain patients. The stories of the patients are just gut wrenching. Chronic pain is just horrible and very hard to understand and treat.
Nah. I'm good.
Maybe I should clarify because my previous comment comes across as dismissive.
We need societal frameworks for empathy and care.
Nothing is ever so easy as just, just, just do this one thing.
I see through people who treat me different because of my pain.
Many of the comments here talk about lifestyle changes, and I think those are key, but there are some, (perhaps rarer) conditions that unfortunately won't be improved.
Trigeminal Neuralgia is one of them. The condition is just... pain. Lot's of pain. More pain than anyone should ever have to go through. When I have episodes, I often feel awe that it's even possible for someone to feel such an incredible amount of pain.
Challenges in life help to shape you, make you who you are. But I do feel that this particular challenge was one where it would have been nice to have learned the same lessons some other way. I hope sincerely that treatment based on this research can help.
Remember when you could measure pain on a scale from 0-10? Then you had to change the scale to 0-1,000,000. Oh my. I'm so glad that's behind me and so much compassion for those that experience it.
This is very interesting, and I think points to the psychosomatic elements of pain, which is probably usually dismissed as "it's all in your head". But really, all pain is "in our head", it just tells us that the pain is elsewhere.
The bigger opportunity here may be not to dismiss pain as being in the head, but recognizing that when it is, treating the suspected source is not the best route, or maybe not in isolation.
I’m currently reading a book, The Way Out by Alan Gordon, on his research into this neuroplastic pain, which is when neural pathways carved by the pain remain after the cause is gone, and how he’s treated it in patients with mental exercises.
I've had cluster headaches my whole life. As a kid I would describe them as "a 40 foot tall giant hammering an ice pick through my skull into my eyeball". Tried a lot for a long time, nothing worked. Sometimes standing in the hottest shower possible until I inexplicably throw up and then feel perfectly fine works, sometimes it doesn't.
There's really no understating the pain, it is not "2 dimensional", which is what I would use to describe every other form of pain I have experienced. It has a shape with immense depth and detail.
Then I got a pretty severe concussion and I mentioned to my doctor at one of the checkups months afterwards that I haven't had any since, they casually threw out "it's entirely possible you're still experiencing them and you just can't feel them now". Scared the hell out of me, but what're you gonna do? They did eventually come back. If we figure it out in my lifetime I'll be damn impressed.
All that said, I wouldn't want to turn pain off. It's important to learn to live with and through it, whatever the source might be, if it cannot be fixed.
That makes no sense. Why would you consider debilitating pain to be important to live through? What is the gain?
It is not like you have a whole lot of choice in the matter so learning how to cope with it is pretty much imperative, besides, the GP may have dependents or other big responsibilities.
I also experienced stabbing sensations like that, although not that severe. For me the root cause turned out to be my diet. Fixed the nutritional deficiencies and accidentally discovered food intolerances. Still have some neurological issues but much better now
"The current work started when Nitsan Goldstein, who was a graduate student in Betley’s lab at the time, found that other urgent survival needs such as thirst and fear can also reduce enduring pain. That finding supported behavioral models developed in collaboration with the Kennedy lab at Scripps, suggest filtering of sensory input at the parabrachial nucleus can block out long-lasting pain when other more acute needs exist.
“That told us the brain must have a built-in way of prioritizing urgent survival needs over pain, and we wanted to find the neurons responsible for that switch,” says Goldstein."
I suffer from frequent headaches, as one way to deal with it I sometimes try to find something that will cause me a different type of discomfort, such as walking several miles. Usually works, eventually.
That's interesting about walking. I've done longish walking pilgrimages lasting several weeks (Camino etc.) and some stomach problems and joint problems improved a lot. I usually walked about 25km a day - I realise that's longer walking than what you mentioned.
There are some books about walking putting illness into remission. A famous one is "The Salt Path" where someone with "corticobasal degeneration" brain disease was positively impacted by their walk. (Although the claims are in doubt now because the main author wasn't truthful about other aspects of their walk)
Anyway walking probably a real positive overall!
I wonder if more light exposure during walking is also a factor? Many folks don’t get enough vitamin D, and light therapy for SAD and other conditions has shown promise as well. I’ve also noticed that 25km+ of daily backpacking for a few weeks continuously helped my overall fitness and wellness, though I don’t have any chronic conditions or ailments at all to speak of. I do question whether many folks would invest the time and effort to do the work, even if they desire the benefits of the exertion.
How do you ensure you aren't just having the same problem most health science runs into:
Doing nothing also usually works eventually for a staggering amount of problems
With impinged nerves in my neck, arm and rear delt, limited (painful) spinal movement so bad I struggled to walk from one part of the house to the other.
My (painful) solution was to get a chiropractor to force movement into my spine and other areas. Pain level 11-10. Slowly thing changed but not enough for my satisfaction. Today I play 2 hours of badminton once a week, train with weights every day and do Dragon Flags to few days a week, go out into the mountains twice a week. Now I'm almost totally pain free and at 67 I can't expect perfection but you never know. By the way this is all done with no medication or painkillers.
I'm 40 and have gotten to the point where after a workout, the target muscles are sore for sometimes 5 or more days, to the point where I can't really exercise other muscles. I've "pushed through" the pain a couple times and it usually ends up causing either an injury or is otherwise quite counter-productive. May I ask, what do you do for recovery that allows you to lift every day?
Often times you need to up protein intake and lower sugar so muscles heal and rebuild in timely manner
Definitely good advice generally! In my case I already consume about 80% body weight in protein per day, and I'm also low carb (<35g per meal, <100g per day), and very rarely intake sugar
I recently got a new hip (at the old age of 36).
Due to said age it was VERY hard to find a doctor willing to replace my hip, EVEN THOUGH I had 2 failed repairs, and had to resort to opioids to sleep.
And long-term opioid usage (not abuse!) can cause higher the risk of persistent pain after a total hip arthroplasty.
Thankfully this is not the case for me. But it was a big concern in this journey.
Wow, you're lucky they even gave you opioids to sleep. Every doctor I know has such bad opio-phobia now that they won't even give them for post-surgery (after you leave the hospital) or broken bones, unless you're at least 50 or 60 years old
I guess I'm lucky the doctor prescribed them to me. I did have a long enough history with him, and showed progress in appointments with hip specialists & PT.
But at the end if I can't sleep, I can't do work and I don't make money. Which is even worse.
After surgery I came home with a good amount of oxy, which to this date is still in its original packaging. Didn't need it.
Oh, and I worked for the consultancy company which essentially caused the opioid crisis, so I was EXTREMELY careful.
This reminds me of an article that I saw 10-20 years ago about delivering small amounts of morphine or another opioid to the spine to stop the transmission of pain as effectively as administering medication to the whole body, using an intrathecal pump:
https://en.wikipedia.org/wiki/Intrathecal_pump
Supposedly there are few or no side effects since the dose is small and localized. Kind of a shame that it's not more broadly known or used IMHO, since I've been close with people with chronic pain whose quality of life was greatly impacted.
It makes me think some of these special breathing exercises can reduce pain for a bit similar to meditation. Include exercise. Fasting as mentioned but it can aggravate other symptoms. Fear inducing scenarios usually reduce pain but it’s short lived. Searching for fear sounds like a terrible idea to calm chronic pain.
I keep coming back to cervical disc issues that don’t heal and continue to worsen. Exercise like jogging can worsen things. Lifting, pt stretching, walking, and no improvements.
I could take a pill but it wouldn’t let me know my limits and I would definitely overextend myself then probably make things worse at a faster pace.
[This research also suggests that behavioral interventions such as exercise, meditation, and cognitive behavioral therapy may influence how these brain circuits fire, just as hunger and fear did in the lab.
“We’ve shown that this circuit is flexible, it can be dialed up or down,” he says. “So, the future isn’t just about designing a pill. It’s also about asking how behavior, training, and lifestyle can change the way these neurons encode pain.”]
My wife has chronic pain from Endo, even after hysterectomy. We think it's in the lining of the abdomen now and the pain looks intense. Cannabis being one of the only things that can take the edge off. I think that many women suffer with this condition but due to the lack of research into it there isn't really anything doctors can do for her, or prescribe her (they've tried many drugs).
Very interesting. I’ve been battling a herniated disk. It’s the most pain I’ve ever been in. Debilitating. Stuart McGill’s “Back Mechanic” is an illuminating read. The “big 3” exercises have become my staple and they seem to mask the pain long before the underlying injury heals, which takes about a year. So the ideas in this article resonate with me. In particular pain itself becoming self perpetuating, and mechanisms to block pain like hunger. My issue is temporary, but it’s introduced me to the reality that some have been handed a lifetime of non negotiable pain. So this is important work.
Pain Brain Film (dot com)
"A documentary that follows the largest fMRI randomized controlled trial challenging conventional wisdom about chronic pain, and revolutionizing treatment for millions."
Explains how these neurons get wired to fire when there is no physical stimulus causing the pain. Similar to phantom limb syndrome.
There's a book called The Way Out, which documents the technique used in the study featured in the Pain Brain Film above.
I can fully attest to this technique. It 100% works. I had chronic neck and back pain for 20 years. I thought it was my desk, I thought it was my posture, thought it was my chair. Nope, it was my mind.
Can't throw us a bone and give a hint what it is? Also, there's no reason not to put the actual link. Unless that's also your email.
Impinged ahoulder and other shoulder pains
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I have another. Hanging (dead hang) from a pullup bar or staircase. It fixes it. 30 seconds every day, or 3 sets of 30 seconds
how do you grip the bar for your dead hang? Wide-grip overhand like a normal pull-up? Or narrow-grip underhand like a chin-up, or both, or something else?
Hi! Overhand like a normal pull-up with a standard grip, hands parallel to shoulders if that makes sense.
Yes it does, thank you! Definitely going to trying this out. Shoulder impingement has been a plague on my lifting
I learnt it from one of those Tiktok Physiotherapist channels. This was some of the benefits I got from Tiktok before I deleted it :)
I would be hesitant to turn off some physical pain like that of an injury I don't want to overextend, but for something like a chronic headache this would be a godsend.
My most effective treatment for headaches is imitrex but you have to time it correctly and I really hate how it makes my body feel.
If areas could be targeted, it could be a massive quality of life improvement for those with endometriosis.
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The question is whether the fire is truly out, or whether the chronic pain is a product of socioeconomics.