With the increase of the awareness and application of the biopsychosocial framework (BPS) of pain and healthcare among manual therapists, I think the “social” piece does not get discussed much on social media, at least within my network. There are a few therapists I know who often include this factors in their discussions, reminding others that we are not just treating pain or structures.

Many of us—including myself—have experienced discrimination in various flavors. In public, we get stares from people because we’re dating someone of a different race, skin color, height, size, gender, etc. We might get rejected in a job application because of how we look and sound—or even just by reading our name. Some of us might even risk getting harassed more often in the streets. For many living in the United States, this is a regular struggle every single day, every breath.

How much does this affect their health and risk of developing chronic pain?

While there is much research in the past 25 years that find a strong association between perceived discrimination and psychological distress, there is no known study that examines the long-term relationship between perceived discrimination and chronic pain development, with psychological distress as a mediator between those two. Recently, however, a team of scientists from the School of Public Health at University of California Berkeley initiated this investigation by digging through data collected by  the National Survey of Midlife in the United States (MIDUS) from 2004-2006 (II) and 2013-2014 (III). (1) MIDUS I (1995-1996) was not collected because the data does not include chronic pain.

Dr. Timothy Brown, who is the Associate Director for Research at Berkeley Center for Health Technology at the University of California Berkeley, led a team of researchers from the School of Public Health department, and they gathered and measured the data. They found that the top four discrimination characteristics are gender, age, height/weight, and race. While race was ranked as relatively low when all the data from MIDUS II is pooled together, it was ranked high when a sample of African-Americans from Milwaukee, Wisconsin, was taken. However, this data cannot be extrapolated to MIDUS III. In MIDUS II, about 19 percent of the sample population suffer from “moderate-to-severe psychological distress,” while the one from MIDUS III has about 33 percent.

In summary, using the latest sample and data, the study estimates that there are 4.1 million people (age 40-plus) suffer from chronic pain because of their experience with discrimination.

​“The MIDUS is a survey collected in a very rigorous manner and is designed to be representative of adults in midlife in the U.S. It also follows the same individuals over time,” Dr. Brown explained in an online interview with Massage & Fitness Magazine. “Data from the MIDUS are used extensively in scientific research. We choose to use the MIDUS because it follows individuals over time, making it possible for us to statistically determine a causal pathway from past discrimination through psychological distress to current chronic pain.”

“You cannot understand biology outside the context of environment,” Prof. Robert Sapolsky.

The study did not specify the type of chronic pain because the researchers wanted to look at chronic pain from a broader neurobiological system that can affect any part of the body.

“Future research is being designed to answer the question of whether there is variation in discrimination-based chronic pain in terms of where chronic pain may present itself. I suspect that such pain will tend to present itself more in some areas of the body (e.g. low back and neck) than in other areas of the body,” Brown speculated.

Overall, the evidence points to a lifetime of perceived discrimination — the micro-nuances many of us face everyday, every week and year — can take a toll on many people’s stress and increase their risk of developing chronic pain. Thus, it is likely that older adults (e.g. African-Americans, transgenders, the disabled) have a significantly higher risk of developing some sort of chronic pain than their younger counterparts who have not yet experienced a higher level of perceived discrimination.

“Older individuals who experienced more discrimination over their lifetime do have a higher risk of experiencing pain sensitivity, other things equal, and the likelihood of experiencing more discrimination would probably be higher for those located in regions of the U.S. with a higher prevalence of racism,” Brown explained. “That said, [with] other things equal, an older person would likely have experienced more of both types of discrimination: daily and lifetime. The measures are different.

“The measure of daily discrimination measures how frequently poor treatment occurs in ordinary situations due to discrimination (e.g., how often people are treated as less intelligent, more dishonest, not as good, etc.). The measure of lifetime discrimination measures whether individuals have experienced various types of discrimination that can have a major life impact (e.g., whether individuals were fired from jobs, not hired for jobs, not given promotions, denied scholarships, denied bank loans, and similar events). Both types of discrimination are important.”

One major limitation of the study is that there is higher a retention rate among women, Whites, married people, and those with higher education and already in good health. Brown et al. mentioned, however, that this does not “impact the internal validity of our study” and their findings may be “understated” because the sample “reflects a population that experiences less discrimination than the general U.S. population.”

When asked what should healthcare professionals consider when they read the research, Brown suggested that they should first find out if the patient has a diagnosis for chronic pain “that is rooted in an actual physical disease process,” which may cause the initial bout of psychological distress but is not the root cause.

“In contrast, a person diagnosed with something such as non-specific low back pain (back pain that has no known pathoanatomical cause) does not have a problem rooted in a diagnosed physical disease process, by definition, although their pain is very real. Both classes of people will benefit from massage, but to the extent that a client’s pain is either accentuated by psychological distress or rooted in psychological distress, there is a great value to encouraging clients to process the issues underlying their stress.” This is where we would refer out if the client or patient is not currently seeing a counselor, psychologist, or a similar qualified professional.

“Our next steps are to broaden our research beyond the question of discrimination causing psychological distress that can result in chronic pain,” Brown continued. “We plan to look at any uncontrollable stressor that may result in psychological distress, and thus, result in chronic pain, and we are also developing machine learning models that can predict who will have chronic pain a decade in the future so that we can develop early prevention protocols.”

“Chronic pain is a horrible, often disabling condition. While much of it is based in chronic disease, a great deal of chronic pain is based in the ordinary stressors of life. Developing protocols to prevent and relieve chronic pain that results from stress would improve the lives of millions of people. I have seen people completely disabled from chronic pain become virtually pain free when they have dealt with their underlying stress issues. Standardizing a protocol to bring people relief could help millions.”



1. Brown TT, Partanen J, Chuong L, Villaverde V, Chantal Griffin A, Mendelson A. Discrimination hurts: The effect of discrimination on the development of chronic pain. Soc Sci Med. 2018 May;204:1-8. doi: 10.1016/j.socscimed.2018.03.015. Epub 2018 Mar 8.

Further Reading

1. Pascoe EA, Smart Richman L. Perceived discrimination and health: a meta-analytic review. Psychol Bull. 2009;135(4):531-54.

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A native of San Diego for nearly 40 years, Nick Ng is an editor of Massage & Fitness Magazine, an online publication for manual therapists and the public who want to explore the science behind touch, pain, and exercise, and how to apply that in their hands-on practice or daily lives.

An alumni from San Diego State University with a B.A. in Graphic Communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014.

When he is not writing or reading, you would likely find him weightlifting at the gym, salsa dancing, or exploring new areas to walk and eat around Southern California.